Provider Demographics
NPI:1114413259
Name:REVIVE QUIROPRACTICA, LLC
Entity Type:Organization
Organization Name:REVIVE QUIROPRACTICA, LLC
Other - Org Name:REVIVE QUIROPRACTICA, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CHIROPRACTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAULINA
Authorized Official - Middle Name:
Authorized Official - Last Name:BARQUERO SOTOMAYOR
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:787-751-1121
Mailing Address - Street 1:902 AVE PONCE DE LEON APT 205
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00907-3348
Mailing Address - Country:US
Mailing Address - Phone:787-430-5357
Mailing Address - Fax:
Practice Address - Street 1:11 CALLE CARAZO
Practice Address - Street 2:
Practice Address - City:GUAYNABO
Practice Address - State:PR
Practice Address - Zip Code:00969-5636
Practice Address - Country:US
Practice Address - Phone:787-430-5357
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PAULINA BARQUERO SOTOMAYOR
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-07-01
Last Update Date:2018-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR632111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR632Medicaid