Healthcare Provider Details

I. General information

NPI: 1477385904
Provider Name (Legal Business Name): REVOLUTIO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2024
Last Update Date: 09/04/2024
Certification Date: 09/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48 E BEAVER CREEK BLVD
AVON CO
81620-7489
US

IV. Provider business mailing address

PO BOX 2646
EDWARDS CO
81632-2646
US

V. Phone/Fax

Practice location:
  • Phone: 970-446-1876
  • Fax:
Mailing address:
  • Phone: 480-232-5217
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DUSTIN STRAIGHT
Title or Position: FOUNDER
Credential: LAC
Phone: 480-232-5217