Provider Demographics
NPI:1730145673
Name:REVAN LLC
Entity Type:Organization
Organization Name:REVAN LLC
Other - Org Name:D/B/A WOUND MANAGEMENT
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:BOOTHBY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:727-869-5551
Mailing Address - Street 1:PO BOX 25513
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33622-5513
Mailing Address - Country:US
Mailing Address - Phone:727-823-2188
Mailing Address - Fax:727-828-0723
Practice Address - Street 1:3890 TAMPA RD STE 201
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684-3677
Practice Address - Country:US
Practice Address - Phone:727-781-3111
Practice Address - Fax:727-781-3113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-20
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS4598207PE0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207PE0005XAllopathic & Osteopathic PhysiciansEmergency MedicineUndersea and Hyperbaric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL069165800Medicaid
FL82569OtherBCBS FL
FL82569OtherBCBS FL