Provider Demographics
NPI:1790809069
Name:REVAN, REBA (CST)
Entity Type:Individual
Prefix:
First Name:REBA
Middle Name:
Last Name:REVAN
Suffix:
Gender:F
Credentials:CST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:241 DEAN RD
Mailing Address - Street 2:
Mailing Address - City:GREER
Mailing Address - State:SC
Mailing Address - Zip Code:29651-7451
Mailing Address - Country:US
Mailing Address - Phone:803-240-2942
Mailing Address - Fax:888-329-6432
Practice Address - Street 1:241 DEAN RD
Practice Address - Street 2:
Practice Address - City:GREER
Practice Address - State:SC
Practice Address - Zip Code:29651-7451
Practice Address - Country:US
Practice Address - Phone:803-240-2942
Practice Address - Fax:888-329-6432
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2009-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist