Healthcare Provider Details

I. General information

NPI: 1003723792
Provider Name (Legal Business Name): REVITALIZATION WELLNESS CONSULTANTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2026
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 FARMERS LN
CHESTER NY
10918-1704
US

IV. Provider business mailing address

4 FARMERS LN
CHESTER NY
10918-1704
US

V. Phone/Fax

Practice location:
  • Phone: 917-687-9317
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State

VIII. Authorized Official

Name: TAISHA BULGIN
Title or Position: OWNER
Credential:
Phone: 917-687-9317