Provider Demographics
NPI:1013553502
Name:REVOLLO, JOSE FELIX
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:FELIX
Last Name:REVOLLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 CLAMOR CT
Mailing Address - Street 2:
Mailing Address - City:FORT WASHINGTON
Mailing Address - State:MD
Mailing Address - Zip Code:20744-5170
Mailing Address - Country:US
Mailing Address - Phone:201-757-4005
Mailing Address - Fax:
Practice Address - Street 1:703 CLAMOR CT
Practice Address - Street 2:
Practice Address - City:FORT WASHINGTON
Practice Address - State:MD
Practice Address - Zip Code:20744-5170
Practice Address - Country:US
Practice Address - Phone:201-757-4005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-20
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN1039386163WR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0400XNursing Service ProvidersRegistered NurseRehabilitation