Provider Demographics
NPI:1649515446
Name:REVOLUTION HEALTH & WELLNESS CLINIC PLLC
Entity type:Organization
Organization Name:REVOLUTION HEALTH & WELLNESS CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:PRESTON
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:918-935-3636
Mailing Address - Street 1:2865 E SKELLY DR STE 300
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74105-6233
Mailing Address - Country:US
Mailing Address - Phone:918-935-3636
Mailing Address - Fax:918-935-3635
Practice Address - Street 1:12142 S YUKON AVE
Practice Address - Street 2:
Practice Address - City:GLENPOOL
Practice Address - State:OK
Practice Address - Zip Code:74033-6621
Practice Address - Country:US
Practice Address - Phone:918-935-3636
Practice Address - Fax:918-935-3635
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-05
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4353207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1790833481OtherPERSONAL NPI NUMBER