Provider Demographics
NPI:1467934414
Name:REVITALIZE MEDICAL CENTER LLC
Entity Type:Organization
Organization Name:REVITALIZE MEDICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHEETAL
Authorized Official - Middle Name:K
Authorized Official - Last Name:DECARIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-834-4018
Mailing Address - Street 1:2550 COMPASS RD UNIT AB
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60026-1610
Mailing Address - Country:US
Mailing Address - Phone:847-834-4018
Mailing Address - Fax:847-834-4944
Practice Address - Street 1:2550 COMPASS RD UNIT AB
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60026-1610
Practice Address - Country:US
Practice Address - Phone:847-834-4018
Practice Address - Fax:847-834-4944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-05
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty