Healthcare Provider Details

I. General information

NPI: 1598097024
Provider Name (Legal Business Name): REVITALIFE TUBS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2010
Last Update Date: 02/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6403 E BEND RD
BURLINGTON KY
41005-9673
US

IV. Provider business mailing address

PO BOX 746
BURLINGTON KY
41005-0746
US

V. Phone/Fax

Practice location:
  • Phone: 859-586-4500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171WV0202X
TaxonomyVehicle Modifications Contractor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License Number
License Number State

VIII. Authorized Official

Name: MR. JOHN WILMHOFF
Title or Position: OWNER
Credential:
Phone: 859-586-4500