Provider Demographics
NPI:1952691495
Name:REVOLUTION CHIROPRACTIC HEALTH CENTER
Entity Type:Organization
Organization Name:REVOLUTION CHIROPRACTIC HEALTH CENTER
Other - Org Name:FREEDOM CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEVON
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:COUGHLIN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:609-668-5456
Mailing Address - Street 1:4516 CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054-2210
Mailing Address - Country:US
Mailing Address - Phone:856-552-0570
Mailing Address - Fax:856-988-1159
Practice Address - Street 1:4516 CHURCH RD
Practice Address - Street 2:
Practice Address - City:MOUNT LAUREL
Practice Address - State:NJ
Practice Address - Zip Code:08054-2210
Practice Address - Country:US
Practice Address - Phone:856-552-0570
Practice Address - Fax:856-988-1159
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-18
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00687000111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty