Provider Demographics
NPI:1497390702
Name:REVISION WELLNESS, LLC
Entity Type:Organization
Organization Name:REVISION WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER -CLINICAL PROVIDER
Authorized Official - Prefix:MISS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:BORRELL
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
Authorized Official - Phone:443-513-0500
Mailing Address - Street 1:11312 MANKLIN CREEK RD UNIT 5
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:MD
Mailing Address - Zip Code:21811-4009
Mailing Address - Country:US
Mailing Address - Phone:443-513-0500
Mailing Address - Fax:888-307-9020
Practice Address - Street 1:11312 MANKLIN CREEK RD UNIT 5
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:MD
Practice Address - Zip Code:21811-4009
Practice Address - Country:US
Practice Address - Phone:443-513-5000
Practice Address - Fax:888-307-9020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-11
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental HealthGroup - Single Specialty
No2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction MedicineGroup - Single Specialty
No2083B0002XAllopathic & Osteopathic PhysiciansPreventive MedicineObesity MedicineGroup - Single Specialty
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive MedicineGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1457683740OtherINDIVIDUAL NPI ASSOCIATED WITH REVISION WELLNESS
MD722026000Medicaid
MD1497390702OtherGROUP NPI