Provider Demographics
NPI:1114540689
Name:REVAN HEALTH LLC
Entity Type:Organization
Organization Name:REVAN HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-896-7975
Mailing Address - Street 1:5601 NW 72ND ST STE 242
Mailing Address - Street 2:
Mailing Address - City:WARR ACRES
Mailing Address - State:OK
Mailing Address - Zip Code:73132-5923
Mailing Address - Country:US
Mailing Address - Phone:405-896-7975
Mailing Address - Fax:866-473-0490
Practice Address - Street 1:5601 NW 72ND ST STE 142
Practice Address - Street 2:
Practice Address - City:WARR ACRES
Practice Address - State:OK
Practice Address - Zip Code:73132-5924
Practice Address - Country:US
Practice Address - Phone:405-896-7975
Practice Address - Fax:866-473-0490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-19
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200917850AMedicaid