Provider Demographics
NPI:1275778763
Name:REVOLUTION CHIROPRACTIC WELLNESS CENTER PLLC
Entity Type:Organization
Organization Name:REVOLUTION CHIROPRACTIC WELLNESS CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:M
Authorized Official - Last Name:HOLMES
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:763-425-4577
Mailing Address - Street 1:8509 JEFFERSON LN N
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55445-2119
Mailing Address - Country:US
Mailing Address - Phone:763-425-4577
Mailing Address - Fax:763-425-2676
Practice Address - Street 1:8509 JEFFERSON LN N
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55445-2119
Practice Address - Country:US
Practice Address - Phone:763-425-4577
Practice Address - Fax:763-425-2676
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-11
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5016111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1093961385OtherPERSONAL NPI FOR SUZANNE HOLMES DC