=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255130621
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REVIVALIFE HEALTH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/10/2025
-----------------------------------------------------
Last Update Date | 10/31/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 E NEW YORK AVE STE 103
-----------------------------------------------------
City | DELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32724-5576
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-901-7215
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 E. NEW YORK AVE STE 103 #1011
-----------------------------------------------------
City | DELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32724-5576
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | EMILY HIDALGO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 407-901-7215
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------