Provider Demographics
NPI:1700051489
Name:REVIVAL HOME
Entity Type:Organization
Organization Name:REVIVAL HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:BENITO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-887-0808
Mailing Address - Street 1:68 W 7TH ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33010-4308
Mailing Address - Country:US
Mailing Address - Phone:305-887-0808
Mailing Address - Fax:305-887-3996
Practice Address - Street 1:68 W 7TH ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33010-4308
Practice Address - Country:US
Practice Address - Phone:305-887-0808
Practice Address - Fax:305-887-3996
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-24
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL9109310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL140707100Medicaid