Provider Demographics
NPI:1598092082
Name:REVOLUTIONARY SERVICES LLC
Entity Type:Organization
Organization Name:REVOLUTIONARY SERVICES LLC
Other - Org Name:STOUT WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALLEN
Authorized Official - Middle Name:EARL
Authorized Official - Last Name:STOUT
Authorized Official - Suffix:
Authorized Official - Credentials:DC FNP-C
Authorized Official - Phone:928-768-2811
Mailing Address - Street 1:5130 HWY 95
Mailing Address - Street 2:
Mailing Address - City:FORT MOHAVE
Mailing Address - State:AZ
Mailing Address - Zip Code:86426-9374
Mailing Address - Country:US
Mailing Address - Phone:928-768-2811
Mailing Address - Fax:928-768-9787
Practice Address - Street 1:5130 HWY 95
Practice Address - Street 2:
Practice Address - City:FORT MOHAVE
Practice Address - State:AZ
Practice Address - Zip Code:86426-9374
Practice Address - Country:US
Practice Address - Phone:928-768-2811
Practice Address - Fax:928-768-9787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-04
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7353111N00000X
261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZV102081Medicare UPIN
AZZ133372Medicare PIN
AZ6562080001Medicare NSC