Provider Demographics
NPI:1316586134
Name:REVIVE CHIROPRACTIC WELLNESS CENTER, INC
Entity Type:Organization
Organization Name:REVIVE CHIROPRACTIC WELLNESS CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NATALIE
Authorized Official - Middle Name:ROSE
Authorized Official - Last Name:RICHARDS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:815-742-0987
Mailing Address - Street 1:5875 E RIVERSIDE BLVD STE 115
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-4937
Mailing Address - Country:US
Mailing Address - Phone:815-398-1689
Mailing Address - Fax:
Practice Address - Street 1:5875 E RIVERSIDE BLVD STE 115
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61114-4937
Practice Address - Country:US
Practice Address - Phone:815-398-1689
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-26
Last Update Date:2019-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty