Provider Demographics
NPI:1386007763
Name:REVITAL LLC
Entity type:Organization
Organization Name:REVITAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MEURET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-254-2420
Mailing Address - Street 1:124 CHESTERFILED TOWNE CTR
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63005-1230
Mailing Address - Country:US
Mailing Address - Phone:314-254-2400
Mailing Address - Fax:636-933-9177
Practice Address - Street 1:124 CHESTERFILED TOWNE CTR
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63005-1230
Practice Address - Country:US
Practice Address - Phone:314-254-2400
Practice Address - Fax:636-933-9177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-01
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty