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General NPI Number Information
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NPI Number | 1679887053
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Entity Type | Organization
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Legal Business Name | REVITAL MEDICAL HEALTH GROUP LLC
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Dates
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Enumeration Date | 07/28/2010
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Last Update Date | 09/11/2013
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Provider Practice Location Address
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Address Line | 17064 W DIXIE HWY
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City | N MIAMI BEACH
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State | FL
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Zip | 33160-3723
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Country | US
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Telephone | 305-949-4964
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Fax | 305-948-6519
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Provider Business Mailing Address
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Address Line | 17064 W DIXIE HWY
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City | NORTH MIAMI BEACH
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State | FL
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Zip | 33160-3723
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Country | US
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Telephone | 305-949-4964
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Fax | 305-948-6519
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. PIERRE A. GASTON
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Credential | M.D.
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Telephone | 305-949-4964
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | ME 41852
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License Number State | FL
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