MEDICARE: REVIVAL HOME SUPPORT L.L.C

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	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1912849985
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REVIVAL HOME SUPPORT L.L.C

Provider Business Mailing Address
First Line	:	8725 WELLESLEY LAKE DR APT 203
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32818-6303
Country	:	US
Telephone Number	:	407-360-7309
Fax Number	:

Provider Business Practice Location Address
First Line	:	8725 WELLESLEY LAKE DR APT 203
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32818-6303
Country	:	US
Telephone Number	:	407-360-7309
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	SARA VERCILISE LAMOTHE
Credential	:
Telephone Number	:	407-360-7309

Provider Enumeration Date	:	04/08/2026
Last Update Date	:	04/08/2026

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