Provider Demographics
NPI:1073385597
Name:REVIVE FAMILY CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:REVIVE FAMILY CHIROPRACTIC LLC
Other - Org Name:REVIVE FAMILY CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHAWNEE
Authorized Official - Middle Name:
Authorized Official - Last Name:MANGINO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:575-207-5757
Mailing Address - Street 1:306 S ALP ST
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48706-4271
Mailing Address - Country:US
Mailing Address - Phone:575-207-5757
Mailing Address - Fax:
Practice Address - Street 1:1203 N MILFORD RD
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:MI
Practice Address - Zip Code:48381-1033
Practice Address - Country:US
Practice Address - Phone:248-714-6127
Practice Address - Fax:248-714-6128
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-27
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty