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General NPI Number Information
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NPI Number | 1679273254
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Entity Type | Organization
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Legal Business Name | REVIVE CONTINUUM
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Dates
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Enumeration Date | 03/03/2023
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Last Update Date | 03/03/2023
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Provider Practice Location Address
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Address Line | 157 LANCASTER ST
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City | BRISTOL
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State | VA
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Zip | 24201-4169
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Country | US
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Telephone | 276-250-5500
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Fax |
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Provider Business Mailing Address
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Address Line | 15329 WOODSTONE CIR
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City | BRISTOL
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State | VA
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Zip | 24202-4023
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Country | US
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Telephone | 276-245-6085
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Fax |
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | JAMES ROSS SHAUBERGER
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Credential | DO
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Telephone | 936-402-2935
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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