Provider Demographics
NPI:1134114176
Name:REVIVAL HOME HEALTH CARE
Entity Type:Organization
Organization Name:REVIVAL HOME HEALTH CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:SPITZER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-629-1000
Mailing Address - Street 1:5350 KINGS HWY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-6703
Mailing Address - Country:US
Mailing Address - Phone:718-629-1000
Mailing Address - Fax:718-629-5151
Practice Address - Street 1:5350 KINGS HWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-6703
Practice Address - Country:US
Practice Address - Phone:718-629-1000
Practice Address - Fax:718-629-5151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7001629251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01544449Medicaid
NY337299Medicare ID - Type Unspecified