Provider Demographics
NPI:1679102248
Name:REVITALIZE LIFE CENTER A PC
Entity type:Organization
Organization Name:REVITALIZE LIFE CENTER A PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING SUPPORT
Authorized Official - Prefix:
Authorized Official - First Name:EBONY
Authorized Official - Middle Name:D
Authorized Official - Last Name:FOSTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-457-6010
Mailing Address - Street 1:3939 ATLANTIC AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90807-3529
Mailing Address - Country:US
Mailing Address - Phone:562-457-6010
Mailing Address - Fax:562-424-5600
Practice Address - Street 1:3939 ATLANTIC AVE STE 100
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-3529
Practice Address - Country:US
Practice Address - Phone:562-457-6010
Practice Address - Fax:562-424-5600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-06
Last Update Date:2020-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty