Provider Demographics
NPI:1700377876
Name:REVERED-HOLISTIC HEALTHCARE LLC
Entity Type:Organization
Organization Name:REVERED-HOLISTIC HEALTHCARE LLC
Other - Org Name:REVERED HOLISTIC HEALTHCARE LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ADETUTU
Authorized Official - Middle Name:
Authorized Official - Last Name:AWODIPE
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:443-621-2203
Mailing Address - Street 1:4518 RUNNYMEADE RD
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-6156
Mailing Address - Country:US
Mailing Address - Phone:443-621-2203
Mailing Address - Fax:
Practice Address - Street 1:1045 TAYLOR AVE STE 44A
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21286-8328
Practice Address - Country:US
Practice Address - Phone:443-621-2203
Practice Address - Fax:410-381-0216
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-24
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR194691363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty