Provider Demographics
NPI:1659026037
Name:REVELRY WELLNESS, LLC
Entity Type:Organization
Organization Name:REVELRY WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DMITRY
Authorized Official - Middle Name:
Authorized Official - Last Name:TURBOVSKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:866-469-1033
Mailing Address - Street 1:7125 ORCHARD LAKE RD STE 210
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-3618
Mailing Address - Country:US
Mailing Address - Phone:866-469-1033
Mailing Address - Fax:
Practice Address - Street 1:7125 ORCHARD LAKE RD STE 210
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-3618
Practice Address - Country:US
Practice Address - Phone:866-469-1033
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-15
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty