=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215724067
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REVITALIZE CLINICS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2025
-----------------------------------------------------
Last Update Date | 04/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 860 NW 42ND AVE STE 406
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33126-4176
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-636-8084
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 860 NW 42ND AVE STE 406
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33126-4176
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-636-8084
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ROBERTO PERDOMO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-215-2999
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------