Healthcare Provider Details

I. General information

NPI: 1699897041
Provider Name (Legal Business Name): REVOLUTION HEALTH MEDICAL CENTER, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2007
Last Update Date: 01/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1641 E OSBORN RD SUITE 6
PHOENIX AZ
85016-7146
US

IV. Provider business mailing address

1641 E OSBORN RD SUITE 6
PHOENIX AZ
85016-7146
US

V. Phone/Fax

Practice location:
  • Phone: 602-265-1774
  • Fax: 602-265-1738
Mailing address:
  • Phone: 602-265-1774
  • Fax: 602-265-1738

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number
License Number State

VIII. Authorized Official

Name: DR. JULIE A GORMAN
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: NMD
Phone: 602-265-1774