Provider Demographics
NPI:1326541715
Name:REVIVE CHIROPRACTIC INC.
Entity Type:Organization
Organization Name:REVIVE CHIROPRACTIC INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BREA
Authorized Official - Middle Name:NEWELL
Authorized Official - Last Name:DANNER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:515-745-3142
Mailing Address - Street 1:241 SE DESTINATION DR STE 300
Mailing Address - Street 2:
Mailing Address - City:GRIMES
Mailing Address - State:IA
Mailing Address - Zip Code:50111-8901
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:241 SE DESTINATION DR STE 300
Practice Address - Street 2:
Practice Address - City:GRIMES
Practice Address - State:IA
Practice Address - Zip Code:50111-8901
Practice Address - Country:US
Practice Address - Phone:515-745-3142
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-13
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA091094111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty