Healthcare Provider Details

I. General information

NPI: 1457088437
Provider Name (Legal Business Name): REVOLUTIONARY CARE CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2022
Last Update Date: 08/01/2023
Certification Date: 08/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1690 S CONGRESS AVE STE 205B
DELRAY BEACH FL
33445-6327
US

IV. Provider business mailing address

1690 S CONGRESS AVE STE 205B
DELRAY BEACH FL
33445-6327
US

V. Phone/Fax

Practice location:
  • Phone: 833-854-3131
  • Fax: 888-979-8674
Mailing address:
  • Phone: 833-854-3131
  • Fax: 888-979-8674

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. JONATHAN CORDERO
Title or Position: OWNER
Credential:
Phone: 833-854-3131