Healthcare Provider Details

I. General information

NPI: 1942904818
Provider Name (Legal Business Name): REVIVE CONCIERGE & WELLNESS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2023
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2961 CROUSE LN
BURLINGTON NC
27215-8833
US

IV. Provider business mailing address

PO BOX 116
SEDALIA NC
27342-0116
US

V. Phone/Fax

Practice location:
  • Phone: 336-266-0518
  • Fax:
Mailing address:
  • Phone: 336-266-7899
  • Fax: 336-234-1020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: CHRYSTAL DANNETTE GUNN GAMMON
Title or Position: OWNER
Credential:
Phone: 336-266-0518