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General NPI Number Information
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NPI Number | 1124902994
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Entity Type | Organization
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Legal Business Name | REVIVE & RENEW
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Dates
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Enumeration Date | 08/04/2025
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Last Update Date | 08/04/2025
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Provider Practice Location Address
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Address Line | 716 S MAIN ST
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City | LOMBARD
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State | IL
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Zip | 60148-3344
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Country | US
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Telephone | 815-573-8464
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Fax |
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Provider Business Mailing Address
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Address Line | 1S122 ELIOT LN
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City | VILLA PARK
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State | IL
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Zip | 60181-3710
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Country | US
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Telephone | 815-573-8464
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Fax |
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Authorized Official
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Title or Position | ADVANCED PRACTICE NURSE
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Name | STEPHANIE WASCHER
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Credential | APN
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Telephone | 815-573-8464
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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