Provider Demographics
NPI:1689063604
Name:SERVILIUS, REVENSON
Entity Type:Individual
Prefix:
First Name:REVENSON
Middle Name:
Last Name:SERVILIUS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:229 GARDEN ST
Mailing Address - Street 2:
Mailing Address - City:WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11590-3840
Mailing Address - Country:US
Mailing Address - Phone:516-849-8700
Mailing Address - Fax:
Practice Address - Street 1:229 GARDEN ST
Practice Address - Street 2:
Practice Address - City:WESTBURY
Practice Address - State:NY
Practice Address - Zip Code:11590
Practice Address - Country:US
Practice Address - Phone:516-849-8700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-14
Last Update Date:2015-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY321208164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse