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General NPI Number Information
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NPI Number | 1265012132
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Entity Type | Organization
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Legal Business Name | REVIVE HOME INFUSION THERAPY LLC
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Dates
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Enumeration Date | 04/13/2021
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Last Update Date | 04/13/2021
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Provider Practice Location Address
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Address Line | 354 W FAIRBANKS AVE
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City | WINTER PARK
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State | FL
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Zip | 32789-5093
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Country | US
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Telephone | 321-972-4243
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Fax | 321-972-4214
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Provider Business Mailing Address
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Address Line | 354 W FAIRBANKS AVE
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City | WINTER PARK
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State | FL
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Zip | 32789-5093
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Country | US
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Telephone | 321-972-4243
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Fax | 321-972-4214
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Authorized Official
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Title or Position | OWNER
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Name | LILIYA HERETSUN-ROUSSONICOLOS
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Credential |
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Telephone | 772-207-6266
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251F00000X
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Taxonomy Name | Home Infusion Agency
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License Number |
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License Number State |
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