Provider Demographics
NPI:1033430418
Name:REVOLUTION MEDICAL SUPPLY
Entity Type:Organization
Organization Name:REVOLUTION MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:NDUKA
Authorized Official - Middle Name:
Authorized Official - Last Name:NDUKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-348-6910
Mailing Address - Street 1:PO BOX 494333
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75049-4333
Mailing Address - Country:US
Mailing Address - Phone:469-348-6910
Mailing Address - Fax:
Practice Address - Street 1:994 E 180TH ST
Practice Address - Street 2:SUITE #4F
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10460-2248
Practice Address - Country:US
Practice Address - Phone:469-348-6910
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-19
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY13417795909700332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies