Healthcare Provider Details

I. General information

NPI: 1780563114
Provider Name (Legal Business Name): JAMES REVORD RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2025
Last Update Date: 08/29/2025
Certification Date: 08/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7171 GLENMEADOW CT
GRAND BLANC MI
48439-7586
US

IV. Provider business mailing address

7171 GLENMEADOW CT
GRAND BLANC MI
48439-7586
US

V. Phone/Fax

Practice location:
  • Phone: 810-938-0720
  • Fax:
Mailing address:
  • Phone: 810-938-0720
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number4704267931
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code163WH1000X
TaxonomyHospice Registered Nurse
License Number4704267931
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code163WC1600X
TaxonomyContinuing Education/Staff Development Registered Nurse
License Number4704267931
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: