Healthcare Provider Details

I. General information

NPI: 1740981877
Provider Name (Legal Business Name): REVITALIZED LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2023
Last Update Date: 03/15/2023
Certification Date: 03/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

231 OLD TOWER HILL RD STE 202
WAKEFIELD RI
02879-3708
US

IV. Provider business mailing address

231 OLD TOWER HILL RD STE 202
WAKEFIELD RI
02879-3708
US

V. Phone/Fax

Practice location:
  • Phone: 401-773-9994
  • Fax:
Mailing address:
  • Phone: 401-773-9994
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251F00000X
TaxonomyHome Infusion Agency
License Number
License Number State

VIII. Authorized Official

Name: NATHANAEL FARRELLY
Title or Position: PRESIDENT
Credential:
Phone: 401-773-9994