Provider Demographics
NPI:1689263345
Name:REVIVAL MEDICAL WEIGHT LOSS CLINIC
Entity Type:Organization
Organization Name:REVIVAL MEDICAL WEIGHT LOSS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:NEALEY
Authorized Official - Last Name:WAINWRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-679-4312
Mailing Address - Street 1:1508 MILITARY CUTOFF RD STE 203
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-5730
Mailing Address - Country:US
Mailing Address - Phone:910-679-4312
Mailing Address - Fax:
Practice Address - Street 1:1508 MILITARY CUTOFF RD STE 203
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-5730
Practice Address - Country:US
Practice Address - Phone:910-679-4312
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-15
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083B0002XAllopathic & Osteopathic PhysiciansPreventive MedicineObesity MedicineGroup - Multi-Specialty