Provider Demographics
NPI:1407115934
Name:REVOLUTION WELLNESS
Entity Type:Organization
Organization Name:REVOLUTION WELLNESS
Other - Org Name:PERFORMANCE CHIROPRACTIC AND SPORTS REHAB, PLLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:BROOKE
Authorized Official - Last Name:DUARTE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:210-771-2136
Mailing Address - Street 1:6011 BROADWAY ST
Mailing Address - Street 2:101
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78209-4554
Mailing Address - Country:US
Mailing Address - Phone:210-771-2136
Mailing Address - Fax:210-247-9463
Practice Address - Street 1:6011 BROADWAY ST
Practice Address - Street 2:101
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78209-4554
Practice Address - Country:US
Practice Address - Phone:210-771-2136
Practice Address - Fax:210-247-9463
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-03
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty