Healthcare Provider Details

I. General information

NPI: 1710640255
Provider Name (Legal Business Name): REVELATION MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2021
Last Update Date: 10/21/2021
Certification Date: 10/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4636 S HARVARD AVE STE 104
TULSA OK
74135-2908
US

IV. Provider business mailing address

4636 S HARVARD AVE STE 104
TULSA OK
74135-2908
US

V. Phone/Fax

Practice location:
  • Phone: 918-398-8900
  • Fax:
Mailing address:
  • Phone: 918-398-8900
  • Fax:

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 Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: JAMES LINN
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 918-398-8900