Provider Demographics
NPI:1255817342
Name:REVIVE CHIROPRACTIC LLC
Entity type:Organization
Organization Name:REVIVE CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALFONSO
Authorized Official - Middle Name:
Authorized Official - Last Name:CHIE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:754-779-4527
Mailing Address - Street 1:18249 PINES BLVD
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33029-1418
Mailing Address - Country:US
Mailing Address - Phone:754-779-4527
Mailing Address - Fax:
Practice Address - Street 1:18249 PINES BLVD
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33029-1418
Practice Address - Country:US
Practice Address - Phone:754-779-4527
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-12
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty