Provider Demographics
NPI:1811723869
Name:REVITA MEDICAL CENTER LLC
Entity type:Organization
Organization Name:REVITA MEDICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ALFREDO
Authorized Official - Middle Name:
Authorized Official - Last Name:PORTAL GARCIA
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:786-922-6393
Mailing Address - Street 1:724 S KROME AVE
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33030-7264
Mailing Address - Country:US
Mailing Address - Phone:786-922-6393
Mailing Address - Fax:
Practice Address - Street 1:724 S KROME AVE
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33030-7264
Practice Address - Country:US
Practice Address - Phone:786-922-6393
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-09
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty