Provider Demographics
NPI:1629828157
Name:REVITALIZE CHIROPRACTIC AND SPORT
Entity Type:Organization
Organization Name:REVITALIZE CHIROPRACTIC AND SPORT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TRINA
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DC, MS
Authorized Official - Phone:256-343-4493
Mailing Address - Street 1:14814 IMPERIAL DR
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:AL
Mailing Address - Zip Code:35613-7456
Mailing Address - Country:US
Mailing Address - Phone:256-343-4493
Mailing Address - Fax:
Practice Address - Street 1:27453 CAPSHAW RD STE E
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:AL
Practice Address - Zip Code:35613-7565
Practice Address - Country:US
Practice Address - Phone:256-343-4493
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-26
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty