Provider Demographics
NPI:1265012132
Name:REVIVE HOME INFUSION THERAPY LLC
Entity Type:Organization
Organization Name:REVIVE HOME INFUSION THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LILIYA
Authorized Official - Middle Name:
Authorized Official - Last Name:HERETSUN-ROUSSONICOLOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-207-6266
Mailing Address - Street 1:354 W FAIRBANKS AVE
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-5093
Mailing Address - Country:US
Mailing Address - Phone:321-972-4243
Mailing Address - Fax:321-972-4214
Practice Address - Street 1:354 W FAIRBANKS AVE
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-5093
Practice Address - Country:US
Practice Address - Phone:321-972-4243
Practice Address - Fax:321-972-4214
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-13
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251F00000XAgenciesHome Infusion