Provider Demographics
NPI:1518327345
Name:REVOLUTIONARY HOME HEATLH, INC
Entity Type:Organization
Organization Name:REVOLUTIONARY HOME HEATLH, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:EVANINA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-383-7502
Mailing Address - Street 1:829 SCRANTON CARBONDALE HWY
Mailing Address - Street 2:
Mailing Address - City:EYNON
Mailing Address - State:PA
Mailing Address - Zip Code:18403-1020
Mailing Address - Country:US
Mailing Address - Phone:570-383-7502
Mailing Address - Fax:
Practice Address - Street 1:1259 S CEDAR CREST BLVD
Practice Address - Street 2:SUITE 255
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18103-6372
Practice Address - Country:US
Practice Address - Phone:484-244-4827
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-07
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA04090501251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
398140Medicare PIN