Provider Demographics
NPI:1518576289
Name:NEW REVELATION HOME CARE LLC
Entity Type:Organization
Organization Name:NEW REVELATION HOME CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KELLIE
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:HAWKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-500-9043
Mailing Address - Street 1:4226 RACCOON PATH
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28312-9369
Mailing Address - Country:US
Mailing Address - Phone:910-500-9043
Mailing Address - Fax:910-500-3012
Practice Address - Street 1:1500 BRAGG BLVD STE 104
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28301-4289
Practice Address - Country:US
Practice Address - Phone:910-500-9043
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-28
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care