Healthcare Provider Details

I. General information

NPI: 1619893120
Provider Name (Legal Business Name): REVITALIZED HOME CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2026
Last Update Date: 06/29/2026
Certification Date: 06/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6152 STONEY OAK LN
MADISON WI
53718-7056
US

IV. Provider business mailing address

6152 STONEY OAK LN
MADISON WI
53718-7056
US

V. Phone/Fax

Practice location:
  • Phone: 608-514-5424
  • Fax:
Mailing address:
  • Phone: 608-514-5424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: NICKI DOSS
Title or Position: OWNER
Credential:
Phone: 608-514-5424