Provider Demographics
NPI:1396103438
Name:REVITALIZE CNY, LLC
Entity type:Organization
Organization Name:REVITALIZE CNY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:M
Authorized Official - Last Name:SETTER
Authorized Official - Suffix:
Authorized Official - Credentials:APRN-BC, DCNP
Authorized Official - Phone:315-251-1234
Mailing Address - Street 1:6800 E GENESEE ST
Mailing Address - Street 2:SUITE 1200
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066-1089
Mailing Address - Country:US
Mailing Address - Phone:315-251-1234
Mailing Address - Fax:315-251-1144
Practice Address - Street 1:6800 E GENESEE ST
Practice Address - Street 2:SUITE 1200
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066-1089
Practice Address - Country:US
Practice Address - Phone:315-251-1234
Practice Address - Fax:315-251-1144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-03
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF335679261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY3835536Medicaid
NY3835536Medicaid