Provider Demographics
NPI:1003199779
Name:REVELATION CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:REVELATION CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:MCMAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:970-377-2250
Mailing Address - Street 1:2721 S COLLEGE AVE UNIT 4A
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-2160
Mailing Address - Country:US
Mailing Address - Phone:970-377-2250
Mailing Address - Fax:970-377-2251
Practice Address - Street 1:2721 S COLLEGE AVE UNIT 4A
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-2160
Practice Address - Country:US
Practice Address - Phone:970-377-2250
Practice Address - Fax:970-377-2251
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-20
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6674111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty