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General NPI Number Information
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NPI Number | 1396103438
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Entity Type | Organization
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Legal Business Name | REVITALIZE CNY, LLC
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Dates
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Enumeration Date | 02/03/2016
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Last Update Date | 02/03/2016
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Provider Practice Location Address
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Address Line | 6800 E GENESEE ST SUITE 1200
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City | FAYETTEVILLE
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State | NY
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Zip | 13066-1089
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Country | US
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Telephone | 315-251-1234
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Fax | 315-251-1144
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Provider Business Mailing Address
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Address Line | 6800 E GENESEE ST SUITE 1200
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City | FAYETTEVILLE
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State | NY
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Zip | 13066-1089
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Country | US
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Telephone | 315-251-1234
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Fax | 315-251-1144
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Authorized Official
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Title or Position | OWNER
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Name | THERESA M. SETTER
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Credential | APRN-BC, DCNP
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Telephone | 315-251-1234
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | F335679
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License Number State | NY
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