MEDICARE: RENVIVA NURSING HOME SERVICES 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	261QE0700X	End-Stage Renal Disease (ESRD) Treatment Clinic/Center

General Provider Information

NPI Number	:	1588167977
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RENVIVA NURSING HOME SERVICES LLC

Provider Business Mailing Address
First Line	:	74444 W. WILSON AVE
Second Line	:	108
City	:	HARWOOD HEIGHTS
State	:	IL
Zip	:	60706-4549
Country	:	US
Telephone Number	:	630-427-8842
Fax Number	:	708-831-4253

Provider Business Practice Location Address
First Line	:	7444 W WILSON AVE
Second Line	:
City	:	HARWOOD HEIGHTS
State	:	IL
Zip	:	60706-4549
Country	:	US
Telephone Number	:	630-427-8842
Fax Number	:	708-831-4253

Authorized Official
Title or Position	:	MEMBER
Name	:	MR. SAMUAL TSAMOULOS
Credential	:
Telephone Number	:	630-427-8842

Provider Enumeration Date	:	03/13/2018
Last Update Date	:	06/16/2018

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