Healthcare Provider Details

I. General information

NPI: 1629399977
Provider Name (Legal Business Name): REVOLUTION HEALTH CENTER PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2010
Last Update Date: 06/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 JAMES RIVER RD
SCOTTSVILLE VA
24590-3812
US

IV. Provider business mailing address

3048 ALBERENE CHURCH LN
ESMONT VA
22937-1516
US

V. Phone/Fax

Practice location:
  • Phone: 434-321-5257
  • Fax: 434-321-5259
Mailing address:
  • Phone: 434-566-7628
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number0101239018
License Number StateVA

VIII. Authorized Official

Name: ZACHARY MONROE BUSH
Title or Position: PRESIDENT
Credential: MD
Phone: 434-566-7628