Provider Demographics
NPI:1245740216
Name:REVENANT CHIROPRACTIC
Entity Type:Organization
Organization Name:REVENANT CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:UBRIN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:724-553-0600
Mailing Address - Street 1:20411 ROUTE 19 UNIT 6
Mailing Address - Street 2:
Mailing Address - City:CRANBERRY TWP
Mailing Address - State:PA
Mailing Address - Zip Code:16066-7511
Mailing Address - Country:US
Mailing Address - Phone:724-799-2251
Mailing Address - Fax:
Practice Address - Street 1:20411 ROUTE 19 UNIT 6
Practice Address - Street 2:
Practice Address - City:CRANBERRY TWP
Practice Address - State:PA
Practice Address - Zip Code:16066-7511
Practice Address - Country:US
Practice Address - Phone:724-799-2251
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-04
Last Update Date:2017-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC011010111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty