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General NPI Number Information
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NPI Number | 1013611490
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Entity Type | Organization
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Legal Business Name | REVOLUTION WELLNESS CENTER LLC
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Dates
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Enumeration Date | 03/29/2023
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Last Update Date | 04/09/2024
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Provider Practice Location Address
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Address Line | 17535 ROSBOUGH BLVD STE 202
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City | MIDDLEBURG HEIGHTS
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State | OH
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Zip | 44130-8362
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Country | US
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Telephone | 216-772-3310
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Fax | 216-251-8502
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Provider Business Mailing Address
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Address Line | 17535 ROSBOUGH BLVD STE 202
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City | MIDDLEBURG HEIGHTS
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State | OH
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Zip | 44130-8362
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Country | US
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Telephone | 216-772-3310
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Fax | 216-251-8502
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Authorized Official
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Title or Position | CHIEF OPERATIONS OFFICER
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Name | DR. JENNIFER ADRIENNE DAVIS
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Credential | PHD
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Telephone | 216-772-3310
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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