Provider Demographics
NPI:1639566557
Name:REVOLUTIONARY HOME HEALTH INC
Entity Type:Organization
Organization Name:REVOLUTIONARY HOME HEALTH INC
Other - Org Name:REVOLUTIONARY HOSPICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANINA
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
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:866-600-7413
Practice Address - Street 1:829 SCRANTON CARBONDALE HWY
Practice Address - Street 2:
Practice Address - City:EYNON
Practice Address - State:PA
Practice Address - Zip Code:18403-1020
Practice Address - Country:US
Practice Address - Phone:570-383-7502
Practice Address - Fax:866-600-7413
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:REVOLUTIONARY HOME HEALTH INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-04-17
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA17641601251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1014816520001Medicaid
391764Medicare PIN