MEDICARE: REVIVE 45 INC

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	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1760162929
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REVIVE 45 INC

Provider Business Mailing Address
First Line	:	9110 S SPAULDING AVE
Second Line	:
City	:	EVERGREEN PARK
State	:	IL
Zip	:	60805-1550
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	10544 S HARLEM AVE # 205
Second Line	:
City	:	PALOS HILLS
State	:	IL
Zip	:	60465-2063
Country	:	US
Telephone Number	:	773-242-9408
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	LAVINA HAMILTON
Credential	:
Telephone Number	:	773-242-9408

Provider Enumeration Date	:	07/24/2023
Last Update Date	:	03/10/2025

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