Revita Life

Primary specialty

Dietary ManagerTaxonomy code 132700000X

License

AN066667 Issued in MI

Legal business name

REVITA LIFE

Practice address

4106 John R
Suite 805
Detroit, MI 48201

Phone

(313) 745-7454

Fax

(313) 993-8625

NPI assigned

Sep 26, 2006

Last updated

Aug 22, 2020By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Andre R Nunn, M.D.

Title

President

Phone

(313) 745-7454

Specialties & licenses 1

Addresses

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1159228800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1225139439",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4106 JOHN R",
            "address_2": "SUITE 805",
            "city": "DETROIT",
            "state": "MI",
            "postal_code": "48201",
            "telephone_number": "313-745-7454",
            "fax_number": "313-993-8625"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4106 JOHN R",
            "address_2": "SUITE 805",
            "city": "DETROIT",
            "state": "MI",
            "postal_code": "48201",
            "telephone_number": "313-745-7454",
            "fax_number": "313-993-8625"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "REVITA LIFE",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-09-26",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "NUNN",
        "authorized_official_first_name": "ANDRE",
        "authorized_official_middle_name": "R",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "313-745-7454",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "132700000X",
            "taxonomy_group": "",
            "desc": "Dietary Manager",
            "state": "MI",
            "license": "AN066667",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Tyjuanique Revere
• Gloria Rey, PAC
• Juan Pablo Reyes Genere, MD
• Esmeralda Reyes-Morales
• Barbara E Reyes, MSW
• Brianna Reyes, RSST

• Dietary Manager in Detroit, MI
• Providers in Detroit, MI by specialty
• Dietary Manager in Michigan

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.