MEDICARE: REVOLUTIONARY CARE CLINIC 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
2	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1457088437
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REVOLUTIONARY CARE CLINIC LLC

Provider Business Mailing Address
First Line	:	1690 S CONGRESS AVE STE 205B
Second Line	:
City	:	DELRAY BEACH
State	:	FL
Zip	:	33445-6327
Country	:	US
Telephone Number	:	833-854-3131
Fax Number	:	888-979-8674

Provider Business Practice Location Address
First Line	:	1690 S CONGRESS AVE STE 205B
Second Line	:
City	:	DELRAY BEACH
State	:	FL
Zip	:	33445-6327
Country	:	US
Telephone Number	:	833-854-3131
Fax Number	:	888-979-8674

Authorized Official
Title or Position	:	OWNER
Name	:	MR. JONATHAN CORDERO
Credential	:
Telephone Number	:	833-854-3131

Provider Enumeration Date	:	08/01/2022
Last Update Date	:	08/01/2023

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