Healthcare Provider Details

I. General information

NPI: 1427593425
Provider Name (Legal Business Name): REVITAL METRO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/29/2016
Last Update Date: 09/04/2024
Certification Date: 09/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1075 VAN VOORHIS RD STE 150
MORGANTOWN WV
26505
US

IV. Provider business mailing address

PO BOX 780
MORGANTOWN WV
26507-0780
US

V. Phone/Fax

Practice location:
  • Phone: 304-598-6216
  • Fax:
Mailing address:
  • Phone: 304-285-7101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: