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General NPI Number Information
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NPI Number | 1366194110
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Entity Type | Organization
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Legal Business Name | REVELATION MEDICAL OF TULSA LLC
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Dates
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Enumeration Date | 01/24/2022
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Last Update Date | 10/03/2023
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Provider Practice Location Address
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Address Line | 4636 S HARVARD AVE STE 104
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City | TULSA
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State | OK
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Zip | 74135-2908
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Country | US
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Telephone | 918-742-4005
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Fax |
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Provider Business Mailing Address
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Address Line | 4636 S HARVARD AVE STE 104
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City | TULSA
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State | OK
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Zip | 74135-2908
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Country | US
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Telephone | 918-742-4005
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Fax |
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Authorized Official
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Title or Position | AUTHORIZED OFFICIAL
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Name | JAMES WARREN LINN
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Credential |
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Telephone | 918-742-4005
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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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 | 225100000X
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Taxonomy Name | Physical Therapist
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207LP2900X
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Taxonomy Name | Pain Medicine (Anesthesiology) Physician
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License Number |
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License Number State |
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