Healthcare Provider Details

I. General information

NPI: 1225139439
Provider Name (Legal Business Name): REVITA LIFE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4106 JOHN R SUITE 805
DETROIT MI
48201
US

IV. Provider business mailing address

4106 JOHN R SUITE 805
DETROIT MI
48201
US

V. Phone/Fax

Practice location:
  • Phone: 313-745-7454
  • Fax: 313-993-8625
Mailing address:
  • Phone: 313-745-7454
  • Fax: 313-993-8625

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code132700000X
TaxonomyDietary Manager
License NumberAN066667
License Number StateMI

VIII. Authorized Official

Name: DR. ANDRE R NUNN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 313-745-7454