Provider Demographics
NPI:1740875095
Name:REVOLUTION FAMILY MEDICINE, PLLC
Entity type:Organization
Organization Name:REVOLUTION FAMILY MEDICINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:M
Authorized Official - Last Name:SLOAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-265-8805
Mailing Address - Street 1:PO BOX 2778
Mailing Address - Street 2:
Mailing Address - City:LILLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27546-2778
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:56 N BROAD ST E
Practice Address - Street 2:
Practice Address - City:ANGIER
Practice Address - State:NC
Practice Address - Zip Code:27501-8964
Practice Address - Country:US
Practice Address - Phone:209-265-8805
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-08
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center