Provider Demographics
NPI:1386223196
Name:REVLIS MEDICAL, LLC
Entity Type:Organization
Organization Name:REVLIS MEDICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKEOWN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:845-551-8166
Mailing Address - Street 1:1040 EDGEWATER PKWY
Mailing Address - Street 2:SUITE 104
Mailing Address - City:INDIAN LAND
Mailing Address - State:SC
Mailing Address - Zip Code:29707-4526
Mailing Address - Country:US
Mailing Address - Phone:845-551-8166
Mailing Address - Fax:
Practice Address - Street 1:1040 EDGEWATER PKWY STE 104
Practice Address - Street 2:SUITE 104
Practice Address - City:INDIAN LAND
Practice Address - State:SC
Practice Address - Zip Code:29707-4526
Practice Address - Country:US
Practice Address - Phone:845-551-8166
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-07
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYX010814OtherNY LICENSE #