Provider Demographics
NPI:1760162929
Name:REVIVE 45 INC
Entity Type:Organization
Organization Name:REVIVE 45 INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EMPLOYEE
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAVINA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMILTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-242-9408
Mailing Address - Street 1:9110 S SPAULDING AVE
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60805-1550
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10544 S HARLEM AVE # 205
Practice Address - Street 2:
Practice Address - City:PALOS HILLS
Practice Address - State:IL
Practice Address - Zip Code:60465-2063
Practice Address - Country:US
Practice Address - Phone:773-242-9408
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-24
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Single Specialty