Healthcare Provider Details

I. General information

NPI: 1558919969
Provider Name (Legal Business Name): REVOLUTION ACCESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2019
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 SHILOH ROAD UNIT 50
ASHEVILLE NC
28803
US

IV. Provider business mailing address

9495 WINNETKA AVE N STE 200
BROOKLYN PARK MN
55445-1618
US

V. Phone/Fax

Practice location:
  • Phone: 828-417-3285
  • Fax: 828-417-3289
Mailing address:
  • Phone: 629-252-8211
  • Fax: 763-255-3972

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code171WV0202X
TaxonomyVehicle Modifications Contractor
License Number
License Number StateNULL

VIII. Authorized Official

Name: KILEY ANN RUSSELL
Title or Position: SENIOR DIRECTOR
Credential:
Phone: 629-252-8211