Provider Demographics
NPI:1922546621
Name:REVOLVE SPINE LLC
Entity Type:Organization
Organization Name:REVOLVE SPINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SANG
Authorized Official - Middle Name:
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:303-738-1725
Mailing Address - Street 1:201 WEST COUNTY LINE ROAD
Mailing Address - Street 2:
Mailing Address - City:LITTLETON
Mailing Address - State:CO
Mailing Address - Zip Code:80129-1901
Mailing Address - Country:US
Mailing Address - Phone:303-738-1725
Mailing Address - Fax:303-738-5876
Practice Address - Street 1:201 WEST COUNTY LINE ROAD
Practice Address - Street 2:
Practice Address - City:LITTLETON
Practice Address - State:CO
Practice Address - Zip Code:80129-1901
Practice Address - Country:US
Practice Address - Phone:303-738-1725
Practice Address - Fax:303-738-5876
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-02
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO7078111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty