Provider Demographics
NPI:1376727610
Name:REVOLUTION MEDICAL CENTER, INC
Entity Type:Organization
Organization Name:REVOLUTION MEDICAL CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:SAGE
Authorized Official - Last Name:HAGGARD
Authorized Official - Suffix:
Authorized Official - Credentials:NMD
Authorized Official - Phone:602-463-7177
Mailing Address - Street 1:2015 E CAMELBACK RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-4710
Mailing Address - Country:US
Mailing Address - Phone:602-840-4400
Mailing Address - Fax:602-840-0490
Practice Address - Street 1:2015 E CAMELBACK RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-4710
Practice Address - Country:US
Practice Address - Phone:602-840-4400
Practice Address - Fax:602-840-0490
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:REVOLUTION MEDICAL CENTER, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-21
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ04836D332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site