Provider Demographics
NPI:1679887053
Name:REVITAL MEDICAL HEALTH GROUP LLC
Entity type:Organization
Organization Name:REVITAL MEDICAL HEALTH GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PIERRE
Authorized Official - Middle Name:A
Authorized Official - Last Name:GASTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-949-4964
Mailing Address - Street 1:17064 W DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33160-3723
Mailing Address - Country:US
Mailing Address - Phone:305-949-4964
Mailing Address - Fax:305-948-6519
Practice Address - Street 1:17064 W DIXIE HWY
Practice Address - Street 2:
Practice Address - City:N MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33160-3723
Practice Address - Country:US
Practice Address - Phone:305-949-4964
Practice Address - Fax:305-948-6519
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-28
Last Update Date:2013-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 41852208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty