Healthcare Provider Details

I. General information

NPI: 1326684259
Provider Name (Legal Business Name): LIFE INTEGRATIVE MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2019
Last Update Date: 11/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2018 EASTWOOD RD
WILMINGTON NC
28403-7228
US

IV. Provider business mailing address

2018 EASTWOOD RD
WILMINGTON NC
28403-7228
US

V. Phone/Fax

Practice location:
  • Phone: 910-787-1358
  • Fax: 910-344-0379
Mailing address:
  • Phone: 910-787-1358
  • Fax: 910-344-0379

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084B0002X
TaxonomyObesity Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0005X
TaxonomyNeurodevelopmental Disabilities Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2084P2900X
TaxonomyPain Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code2084S0010X
TaxonomySports Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 8
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: JEREMY REVELL
Title or Position: OWNER/PROVIDER
Credential: MD
Phone: 323-216-0993