1780339663 NPI number — REVIVE HEALTHCARE PC

Table of content: DR. CHARLES ALLEN RODMAN IV D.O. (NPI 1013124031)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780339663 NPI number — REVIVE HEALTHCARE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
REVIVE HEALTHCARE PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1780339663
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/18/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
REVIVE HEALTHCARE PC
Provider Second Line Business Mailing Address:
265 EASTCHESTER DRIVE, SUITE 133, # 173
Provider Business Mailing Address City Name:
HIGH POINT
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27262
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-687-4382
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
221 HILLCREST DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HIGH POINT
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27262-3037
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-687-4382
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/18/2022

Additional Information

Authorized Official

Authorized Official Last Name:
ESKEW
Authorized Official First Name:
LAWRENCE
Authorized Official Middle Name:
ANDREW
Authorized Official Title or Position:
CEO AND CMO
Authorized Official Telephone Number:
336-687-4382

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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