Provider Demographics
NPI:1578181277
Name:REVERE WELLNESS LLC
Entity Type:Organization
Organization Name:REVERE WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:865-455-4817
Mailing Address - Street 1:1333 MEADOWBROOK DR
Mailing Address - Street 2:
Mailing Address - City:PULASKI
Mailing Address - State:TN
Mailing Address - Zip Code:38478-5002
Mailing Address - Country:US
Mailing Address - Phone:865-455-4817
Mailing Address - Fax:
Practice Address - Street 1:1333 MEADOWBROOK DR
Practice Address - Street 2:
Practice Address - City:PULASKI
Practice Address - State:TN
Practice Address - Zip Code:38478-5002
Practice Address - Country:US
Practice Address - Phone:865-455-4817
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-08
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center