Provider Demographics
NPI:1891452371
Name:REVITALIZE CHIROPRACTIC, LLC
Entity Type:Organization
Organization Name:REVITALIZE CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARRETT
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:SCHULTZ
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:701-532-1672
Mailing Address - Street 1:26748 130TH AVE N
Mailing Address - Street 2:
Mailing Address - City:ULEN
Mailing Address - State:MN
Mailing Address - Zip Code:56585-9629
Mailing Address - Country:US
Mailing Address - Phone:701-212-3632
Mailing Address - Fax:
Practice Address - Street 1:4575 23RD AVE S STE 1100
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-9052
Practice Address - Country:US
Practice Address - Phone:701-532-1672
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-19
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty