Provider Demographics
NPI:1538505581
Name:REVIVE CHIROPRACTIC AND REHABLILITATION LLC
Entity Type:Organization
Organization Name:REVIVE CHIROPRACTIC AND REHABLILITATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PRESTON
Authorized Official - Middle Name:
Authorized Official - Last Name:MULLENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-382-5576
Mailing Address - Street 1:12875 ROUTE 30
Mailing Address - Street 2:SUITE 25
Mailing Address - City:NORTH HUNTINGDON
Mailing Address - State:PA
Mailing Address - Zip Code:15642-2595
Mailing Address - Country:US
Mailing Address - Phone:724-383-5576
Mailing Address - Fax:
Practice Address - Street 1:12875 ROUTE 30
Practice Address - Street 2:SUITE 25
Practice Address - City:NORTH HUNTINGDON
Practice Address - State:PA
Practice Address - Zip Code:15642-2595
Practice Address - Country:US
Practice Address - Phone:724-383-5576
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-17
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC010524111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty