Provider Demographics
NPI:1417694704
Name:REVOLUTION HEALTHCARE LLC
Entity Type:Organization
Organization Name:REVOLUTION HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:CLAIBORNE
Authorized Official - Middle Name:TUCKER
Authorized Official - Last Name:PERDUE
Authorized Official - Suffix:III
Authorized Official - Credentials:NP
Authorized Official - Phone:804-387-2635
Mailing Address - Street 1:3214 SEMINARY AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23227-4821
Mailing Address - Country:US
Mailing Address - Phone:804-387-2635
Mailing Address - Fax:
Practice Address - Street 1:3214 SEMINARY AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23227-4821
Practice Address - Country:US
Practice Address - Phone:804-387-2635
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-18
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care