Provider Demographics
NPI:1326684259
Name:LIFE INTEGRATIVE MEDICINE
Entity Type:Organization
Organization Name:LIFE INTEGRATIVE MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:
Authorized Official - Last Name:REVELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-216-0993
Mailing Address - Street 1:2018 EASTWOOD RD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-7228
Mailing Address - Country:US
Mailing Address - Phone:910-787-1358
Mailing Address - Fax:910-344-0379
Practice Address - Street 1:2018 EASTWOOD RD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-7228
Practice Address - Country:US
Practice Address - Phone:910-787-1358
Practice Address - Fax:910-344-0379
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-26
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction MedicineGroup - Multi-Specialty
No2084B0002XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyObesity MedicineGroup - Multi-Specialty
No2084P0005XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurodevelopmental DisabilitiesGroup - Multi-Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric PsychiatryGroup - Multi-Specialty
No2084P2900XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPain MedicineGroup - Multi-Specialty
No2084S0010XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySports MedicineGroup - Multi-Specialty