Provider Demographics
NPI:1285202143
Name:REVIVE CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:REVIVE CHIROPRACTIC LLC
Other - Org Name:REVIVE CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/AO
Authorized Official - Prefix:DR
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:JOSHUA
Authorized Official - Last Name:CARR
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:978-851-0515
Mailing Address - Street 1:PO BOX 99
Mailing Address - Street 2:
Mailing Address - City:OWEN
Mailing Address - State:WI
Mailing Address - Zip Code:54460-0099
Mailing Address - Country:US
Mailing Address - Phone:715-229-0262
Mailing Address - Fax:
Practice Address - Street 1:107 S HARDING ST
Practice Address - Street 2:
Practice Address - City:OWEN
Practice Address - State:WI
Practice Address - Zip Code:54460-9737
Practice Address - Country:US
Practice Address - Phone:715-229-0262
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-16
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty