Provider Demographics
NPI:1164572566
Name:REVILLA CHIROPRACTIC A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:REVILLA CHIROPRACTIC A PROFESSIONAL CORPORATION
Other - Org Name:COMPREHENSIVE HEALTH AND CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:REVILLA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:760-736-0286
Mailing Address - Street 1:555 S RANCHO SANTA FE RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92078-3698
Mailing Address - Country:US
Mailing Address - Phone:760-736-0286
Mailing Address - Fax:760-736-3113
Practice Address - Street 1:555 S RANCHO SANTA FE RD
Practice Address - Street 2:SUITE 200
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92078-3698
Practice Address - Country:US
Practice Address - Phone:760-736-0286
Practice Address - Fax:760-736-3113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC 20363111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC20363Medicare ID - Type UnspecifiedMEDICARE ID
CADC24577Medicare ID - Type UnspecifiedMEDICARE ID