Provider Demographics
NPI:1700165818
Name:KOHLI LLC
Entity Type:Organization
Organization Name:KOHLI LLC
Other - Org Name:REVOLUTION MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-942-1015
Mailing Address - Street 1:603 REVOLUTION ST
Mailing Address - Street 2:
Mailing Address - City:HAVRE DE GRACE
Mailing Address - State:MD
Mailing Address - Zip Code:21078-3319
Mailing Address - Country:US
Mailing Address - Phone:410-942-1015
Mailing Address - Fax:410-942-1016
Practice Address - Street 1:603 REVOLUTION ST
Practice Address - Street 2:
Practice Address - City:HAVRE DE GRACE
Practice Address - State:MD
Practice Address - Zip Code:21078-3319
Practice Address - Country:US
Practice Address - Phone:410-942-1015
Practice Address - Fax:410-942-1016
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-06
Last Update Date:2011-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD 71586174400000X
MDD 50806174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty