Provider Demographics
NPI:1336498906
Name:REVIVAL HOME CARE
Entity Type:Organization
Organization Name:REVIVAL HOME CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CAREGIVER
Authorized Official - Prefix:MRS
Authorized Official - First Name:FIDELITE
Authorized Official - Middle Name:
Authorized Official - Last Name:KANKINDI
Authorized Official - Suffix:
Authorized Official - Credentials:MBR
Authorized Official - Phone:623-297-1305
Mailing Address - Street 1:8269 W STATE AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85303
Mailing Address - Country:US
Mailing Address - Phone:602-334-4187
Mailing Address - Fax:602-334-4187
Practice Address - Street 1:8269 W STATE AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85303
Practice Address - Country:US
Practice Address - Phone:602-334-4187
Practice Address - Fax:602-334-4187
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-29
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL8758H3104A0630X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances