Healthcare Provider Details

I. General information

NPI: 1760958078
Provider Name (Legal Business Name): CONSTANCE REVORE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2018
Last Update Date: 05/21/2025
Certification Date: 05/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1263 MISSION ST
SAN FRANCISCO CA
94103-2705
US

IV. Provider business mailing address

1263 MISSION ST
SAN FRANCISCO CA
94103-2705
US

V. Phone/Fax

Practice location:
  • Phone: 415-948-7384
  • Fax:
Mailing address:
  • Phone: 415-597-8047
  • Fax: 415-597-8004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: