Provider Demographics
NPI:1912472200
Name:REVELATION FAMILY MEDICINE OFFICE, LLC.
Entity Type:Organization
Organization Name:REVELATION FAMILY MEDICINE OFFICE, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED PHYSICIAN ASSISTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEAN-MARCEL
Authorized Official - Middle Name:
Authorized Official - Last Name:FORTE
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:305-807-4283
Mailing Address - Street 1:3939 HOLLYWOOD BLVD STE 300B
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-6749
Mailing Address - Country:US
Mailing Address - Phone:786-863-8633
Mailing Address - Fax:
Practice Address - Street 1:3939 HOLLYWOOD BLVD STE 300B
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-6749
Practice Address - Country:US
Practice Address - Phone:786-863-8633
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-12
Last Update Date:2018-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty