Healthcare Provider Details

I. General information

NPI: 1215724067
Provider Name (Legal Business Name): REVITALIZE CLINICS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2025
Last Update Date: 04/24/2025
Certification Date: 04/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

860 NW 42ND AVE STE 406
MIAMI FL
33126-4176
US

IV. Provider business mailing address

860 NW 42ND AVE STE 406
MIAMI FL
33126-4176
US

V. Phone/Fax

Practice location:
  • Phone: 786-636-8084
  • Fax:
Mailing address:
  • Phone: 786-636-8084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: ROBERTO PERDOMO
Title or Position: OWNER
Credential:
Phone: 305-215-2999