Provider Demographics
NPI:1548773708
Name:REVIVE CHIROPRACTIC, LLC
Entity Type:Organization
Organization Name:REVIVE CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, OFFICE MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:
Authorized Official - Last Name:AUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-621-4390
Mailing Address - Street 1:2205 W MARKET ST
Mailing Address - Street 2:
Mailing Address - City:POTTSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17901-1803
Mailing Address - Country:US
Mailing Address - Phone:570-621-4390
Mailing Address - Fax:570-621-4296
Practice Address - Street 1:2205 W MARKET ST
Practice Address - Street 2:
Practice Address - City:POTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17901-1803
Practice Address - Country:US
Practice Address - Phone:570-621-4390
Practice Address - Fax:570-621-4296
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-09
Last Update Date:2019-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1548773708OtherNPI