Provider Demographics
NPI:1780192674
Name:REVITALIZE CHIROPRACTIC, LLC
Entity Type:Organization
Organization Name:REVITALIZE CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:CHRISTINE
Authorized Official - Last Name:CHAPEL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:636-537-0564
Mailing Address - Street 1:936 CHESTERFIELD PKWY E
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-2042
Mailing Address - Country:US
Mailing Address - Phone:636-537-0564
Mailing Address - Fax:
Practice Address - Street 1:936 CHESTERFIELD PKWY E
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-2042
Practice Address - Country:US
Practice Address - Phone:636-537-0564
Practice Address - Fax:314-775-9870
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-14
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty