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General NPI Number Information
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NPI Number | 1255627477
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Entity Type | Individual
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Provider Name | ADRIAN ALEXANDER MANCHENO REVELO MD
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Gender | Male
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Dates
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Enumeration Date | 06/27/2011
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Last Update Date | 08/05/2014
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Provider Practice Location Address
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Address Line | 1214 VAUGHN RD 1 ST FLOOR
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City | BURLINGTON
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State | NC
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Zip | 27217-2863
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Country | US
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Telephone | 919-537-7473
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Fax |
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Provider Business Mailing Address
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Address Line | 1105 CLARENDON ST
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City | DURHAM
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State | NC
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Zip | 27705-3511
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Country | US
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Telephone | 828-551-8654
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 172999
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License Number State | NC
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