MEDICARE: REVITAL LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1386007763
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REVITAL LLC

Provider Business Mailing Address
First Line	:	124 CHESTERFILED TOWNE CTR
Second Line	:
City	:	CHESTERFIELD
State	:	MO
Zip	:	63005-1230
Country	:	US
Telephone Number	:	314-254-2400
Fax Number	:	636-933-9177

Provider Business Practice Location Address
First Line	:	124 CHESTERFILED TOWNE CTR
Second Line	:
City	:	CHESTERFIELD
State	:	MO
Zip	:	63005-1230
Country	:	US
Telephone Number	:	314-254-2400
Fax Number	:	636-933-9177

Authorized Official
Title or Position	:	OWNER/CEO
Name	:	KEVIN MEURET
Credential	:
Telephone Number	:	314-254-2420

Provider Enumeration Date	:	04/01/2016
Last Update Date	:	04/01/2016

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Directions to “REVITAL LLC ” Practice Location

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