Healthcare Provider Details

I. General information

NPI: 1093764805
Provider Name (Legal Business Name): REVERE HEALTH PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 09/02/2025
Certification Date: 07/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 N 500 W
PROVO UT
84604-3305
US

IV. Provider business mailing address

1055 N 500 W CREDENTIALING DEPARTMENT
PROVO UT
84604-3305
US

V. Phone/Fax

Practice location:
  • Phone: 801-429-8000
  • Fax: 801-429-8150
Mailing address:
  • Phone: 801-354-8225
  • Fax: 801-418-0941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JED HARSTON
Title or Position: DIRECTOR OF MANAGED CARE
Credential:
Phone: 801-812-5012