Provider Demographics
NPI:1902003916
Name:REVELATIONS CHIROPRACTIC, INC.
Entity Type:Organization
Organization Name:REVELATIONS CHIROPRACTIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:M
Authorized Official - Last Name:MONDEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:405-736-6850
Mailing Address - Street 1:1212 S AIR DEPOT BLVD
Mailing Address - Street 2:SUITE 31
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73110-4870
Mailing Address - Country:US
Mailing Address - Phone:405-736-6850
Mailing Address - Fax:405-736-6823
Practice Address - Street 1:1212 S AIR DEPOT BLVD
Practice Address - Street 2:SUITE 31
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110-4870
Practice Address - Country:US
Practice Address - Phone:405-736-6850
Practice Address - Fax:405-736-6823
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-02
Last Update Date:2012-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3698111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK500522103Medicare ID - Type UnspecifiedMEDICARE GROUP #