Provider Demographics
NPI:1629134804
Name:REVIVE CHIROPRACTIC
Entity Type:Organization
Organization Name:REVIVE CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WITOLD
Authorized Official - Middle Name:T
Authorized Official - Last Name:GOZDALSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-282-4300
Mailing Address - Street 1:6615 W IRVING PARK RD
Mailing Address - Street 2:STE. #301
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60634-2410
Mailing Address - Country:US
Mailing Address - Phone:772-282-4300
Mailing Address - Fax:
Practice Address - Street 1:6615 W IRVING PARK RD
Practice Address - Street 2:STE. #301
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60634-2410
Practice Address - Country:US
Practice Address - Phone:772-282-4300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-29
Last Update Date:2008-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN038-009590111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1633769OtherBCBS OF IL
IL1633769OtherBCBS OF IL
ILDD8945Medicare ID - Type UnspecifiedRAILROAD MEDICARE GRP #