Provider Demographics
NPI:1912759820
Name:REVITALIFE MEDICAL CENTER
Entity Type:Organization
Organization Name:REVITALIFE MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:KHOI
Authorized Official - Middle Name:
Authorized Official - Last Name:VU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-545-1154
Mailing Address - Street 1:14650 AVIATION BLVD
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-6668
Mailing Address - Country:US
Mailing Address - Phone:310-545-1154
Mailing Address - Fax:310-545-1132
Practice Address - Street 1:14650 AVIATION BLVD
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250-6668
Practice Address - Country:US
Practice Address - Phone:310-545-1154
Practice Address - Fax:310-545-1132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-03
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty