Provider Demographics
NPI:1518320589
Name:REVITAL LLC
Entity Type:Organization
Organization Name:REVITAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MEURET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-254-2420
Mailing Address - Street 1:101 MAIN ST
Mailing Address - Street 2:SUITE 2300 B
Mailing Address - City:FESTUS
Mailing Address - State:MO
Mailing Address - Zip Code:63028-1977
Mailing Address - Country:US
Mailing Address - Phone:314-254-2420
Mailing Address - Fax:636-933-9177
Practice Address - Street 1:101 MAIN ST
Practice Address - Street 2:SUITE 2300 B
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028-1977
Practice Address - Country:US
Practice Address - Phone:314-254-2420
Practice Address - Fax:636-933-9177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-29
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty