Healthcare Provider Details

I. General information

NPI: 1649515446
Provider Name (Legal Business Name): REVOLUTION HEALTH & WELLNESS CLINIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2012
Last Update Date: 02/22/2021
Certification Date: 02/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12142 S YUKON AVE
GLENPOOL OK
74033-6621
US

IV. Provider business mailing address

2865 E SKELLY DR STE 300
TULSA OK
74105-6233
US

V. Phone/Fax

Practice location:
  • Phone: 918-935-3636
  • Fax: 918-935-3635
Mailing address:
  • Phone: 918-935-3636
  • Fax: 918-935-3635

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4353
License Number StateOK

VIII. Authorized Official

Name: DR. CHAD PRESTON EDWARDS
Title or Position: PHYSICIAN/OWNER
Credential: D.O.
Phone: 918-935-3636