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General NPI Number Information
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NPI Number | 1093764805
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Entity Type | Organization
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Legal Business Name | REVERE HEALTH PC
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Dates
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Enumeration Date | 05/09/2006
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Last Update Date | 09/02/2025
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Provider Practice Location Address
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Address Line | 1055 N 500 W
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City | PROVO
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State | UT
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Zip | 84604-3305
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Country | US
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Telephone | 801-429-8000
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Fax | 801-429-8150
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Provider Business Mailing Address
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Address Line | 1055 N 500 W CREDENTIALING DEPARTMENT
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City | PROVO
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State | UT
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Zip | 84604-3305
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Country | US
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Telephone | 801-354-8225
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Fax | 801-418-0941
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Authorized Official
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Title or Position | DIRECTOR OF MANAGED CARE
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Name | JED HARSTON
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Credential |
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Telephone | 801-812-5012
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number |
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License Number State |
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