MEDICARE: REVELATION HEALTH & WELLNESS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1063072551
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REVELATION HEALTH & WELLNESS LLC

Provider Business Mailing Address
First Line	:	249 OLSON DR STE 103
Second Line	:
City	:	PAPILLION
State	:	NE
Zip	:	68046-2974
Country	:	US
Telephone Number	:	402-715-4855
Fax Number	:	402-916-4169

Provider Business Practice Location Address
First Line	:	249 OLSON DR STE 103
Second Line	:
City	:	PAPILLION
State	:	NE
Zip	:	68046-2974
Country	:	US
Telephone Number	:	712-269-8177
Fax Number	:

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. BROOK LAPKE
Credential	:
Telephone Number	:	402-715-4855

Provider Enumeration Date	:	06/17/2019
Last Update Date	:	10/22/2019

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