Provider Demographics
NPI:1861871402
Name:REVOLUTION NEUROMONITORING, LLC
Entity type:Organization
Organization Name:REVOLUTION NEUROMONITORING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JEREMIAH
Authorized Official - Middle Name:TITUS
Authorized Official - Last Name:VANCE
Authorized Official - Suffix:
Authorized Official - Credentials:CNIM
Authorized Official - Phone:214-295-6703
Mailing Address - Street 1:6437 SOUTHPOINT DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75248
Mailing Address - Country:US
Mailing Address - Phone:214-295-6703
Mailing Address - Fax:469-385-8892
Practice Address - Street 1:6437 SOUTHPOINT DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75248-2109
Practice Address - Country:US
Practice Address - Phone:214-295-6703
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-28
Last Update Date:2017-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnosticGroup - Single Specialty