Provider Demographics
NPI:1417522186
Name:REVIVE PBG LLC
Entity Type:Organization
Organization Name:REVIVE PBG LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:MCNABB
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:561-531-9320
Mailing Address - Street 1:5320 DONALD ROSS RD STE 125
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33418-7296
Mailing Address - Country:US
Mailing Address - Phone:561-531-9320
Mailing Address - Fax:772-413-7025
Practice Address - Street 1:5320 DONALD ROSS RD STE 125
Practice Address - Street 2:
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33418-7296
Practice Address - Country:US
Practice Address - Phone:561-531-9320
Practice Address - Fax:772-413-7025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-25
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty