Provider Demographics
NPI:1740680784
Name:REVITA, MARIA-CELIA FLORENCE
Entity type:Individual
Prefix:MRS
First Name:MARIA-CELIA
Middle Name:FLORENCE
Last Name:REVITA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARIA-CELIA
Other - Middle Name:REVITA
Other - Last Name:JANICE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13101 ALLEN RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHGATE
Mailing Address - State:MI
Mailing Address - Zip Code:48195-2216
Mailing Address - Country:US
Mailing Address - Phone:734-785-7700
Mailing Address - Fax:
Practice Address - Street 1:13101 ALLEN RD
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-2216
Practice Address - Country:US
Practice Address - Phone:734-785-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-27
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL2427174247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other