Provider Demographics
NPI:1225306608
Name:REVITALIFE CENTER, P.A.
Entity Type:Organization
Organization Name:REVITALIFE CENTER, P.A.
Other - Org Name:REVITALIFE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:763-710-4085
Mailing Address - Street 1:8097 HIGHWAY 65 NE STE 102
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55432-4511
Mailing Address - Country:US
Mailing Address - Phone:763-710-4085
Mailing Address - Fax:
Practice Address - Street 1:8097 HIGHWAY 65 NE STE 102
Practice Address - Street 2:
Practice Address - City:SPRING LAKE PARK
Practice Address - State:MN
Practice Address - Zip Code:55432-4511
Practice Address - Country:US
Practice Address - Phone:763-710-4085
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-13
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5552111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty