Provider Demographics
NPI:1508551300
Name:REVIVE CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:REVIVE CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLE
Authorized Official - Middle Name:J
Authorized Official - Last Name:SNYDER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:817-422-4246
Mailing Address - Street 1:2229 SUN STAR DR
Mailing Address - Street 2:
Mailing Address - City:HASLET
Mailing Address - State:TX
Mailing Address - Zip Code:76052-3499
Mailing Address - Country:US
Mailing Address - Phone:817-422-4246
Mailing Address - Fax:
Practice Address - Street 1:12517 N SAGINAW BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76179
Practice Address - Country:US
Practice Address - Phone:817-422-4246
Practice Address - Fax:817-288-0775
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-07
Last Update Date:2023-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty