Provider Demographics
NPI:1821516683
Name:A REVOLUTION MEDICAL
Entity Type:Organization
Organization Name:A REVOLUTION MEDICAL
Other - Org Name:A REVOLUTION MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MGR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:G
Authorized Official - Last Name:CARDER
Authorized Official - Suffix:
Authorized Official - Credentials:DOM
Authorized Official - Phone:407-808-8763
Mailing Address - Street 1:711 N ORLANDO AVE
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-4403
Mailing Address - Country:US
Mailing Address - Phone:407-636-5391
Mailing Address - Fax:407-986-4404
Practice Address - Street 1:711 N ORLANDO AVE
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-4403
Practice Address - Country:US
Practice Address - Phone:407-636-5391
Practice Address - Fax:407-986-4404
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ALPHA HEALTH LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-08-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAP2102OtherFLORIDA LICENSE