Provider Demographics
NPI:1225681653
Name:CHIROSPA REVIVE
Entity Type:Organization
Organization Name:CHIROSPA REVIVE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BORNE-NUSOM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:240-779-1203
Mailing Address - Street 1:5512 RIO ALAMO ST
Mailing Address - Street 2:
Mailing Address - City:ROSHARON
Mailing Address - State:TX
Mailing Address - Zip Code:77583-4002
Mailing Address - Country:US
Mailing Address - Phone:240-779-1203
Mailing Address - Fax:
Practice Address - Street 1:9896 BISSONNET ST STE 133
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77036-8104
Practice Address - Country:US
Practice Address - Phone:240-779-1203
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-24
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty