Provider Demographics
NPI:1356015218
Name:REVOLUTION HEALTH LLC
Entity Type:Organization
Organization Name:REVOLUTION HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BASS
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:702-703-1202
Mailing Address - Street 1:6301 MOUNTAIN VISTA ST STE 209
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89014-2364
Mailing Address - Country:US
Mailing Address - Phone:702-703-1202
Mailing Address - Fax:
Practice Address - Street 1:6301 MOUNTAIN VISTA ST STE 209
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89014-2364
Practice Address - Country:US
Practice Address - Phone:702-703-1202
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-04
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV250011291Medicaid