Provider Demographics
NPI:1366169989
Name:REVITAL RETREAT, LLC
Entity type:Organization
Organization Name:REVITAL RETREAT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADVANCE PRACTICE NURSE/ OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EVELYN
Authorized Official - Middle Name:
Authorized Official - Last Name:JAVIER
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:732-589-9388
Mailing Address - Street 1:371 HOES LN STE 200
Mailing Address - Street 2:
Mailing Address - City:PISCATAWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:08854-4143
Mailing Address - Country:US
Mailing Address - Phone:732-660-8029
Mailing Address - Fax:732-358-2921
Practice Address - Street 1:371 HOES LN STE 200
Practice Address - Street 2:
Practice Address - City:PISCATAWAY
Practice Address - State:NJ
Practice Address - Zip Code:08854-4143
Practice Address - Country:US
Practice Address - Phone:732-660-8029
Practice Address - Fax:732-358-2921
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-25
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1881653608Medicaid