Provider Demographics
NPI:1942904818
Name:REVIVE CONCIERGE & WELLNESS PLLC
Entity Type:Organization
Organization Name:REVIVE CONCIERGE & WELLNESS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:GAMMON
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:434-429-2383
Mailing Address - Street 1:PO BOX 116
Mailing Address - Street 2:
Mailing Address - City:SEDALIA
Mailing Address - State:NC
Mailing Address - Zip Code:27342-0116
Mailing Address - Country:US
Mailing Address - Phone:336-266-7899
Mailing Address - Fax:336-234-1020
Practice Address - Street 1:906 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27215-5757
Practice Address - Country:US
Practice Address - Phone:336-935-1240
Practice Address - Fax:336-234-1020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-27
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty