MEDICARE: REVITALIZE NUTRITION CORP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QI0500X	Infusion Therapy Clinic/Center

General Provider Information

NPI Number	:	1306635537
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REVITALIZE NUTRITION CORP

Provider Business Mailing Address
First Line	:	7308 N WESTERN AVE
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73116-7120
Country	:	US
Telephone Number	:	405-625-6488
Fax Number	:

Provider Business Practice Location Address
First Line	:	7308 N WESTERN AVE
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73116-7120
Country	:	US
Telephone Number	:	405-625-6488
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DAVID MEYER
Credential	:	RN
Telephone Number	:	405-201-0001

Provider Enumeration Date	:	05/05/2025
Last Update Date	:	05/05/2025

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