Provider Demographics
NPI:1952698680
Name:REVIVE INJURY AND WELLNESS, PC
Entity Type:Organization
Organization Name:REVIVE INJURY AND WELLNESS, PC
Other - Org Name:VERMILLION & BLOOM, PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIN
Authorized Official - Middle Name:DANIELLE
Authorized Official - Last Name:BLOOM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:503-344-4378
Mailing Address - Street 1:1750 BLANKENSHIP RD
Mailing Address - Street 2:SUITE 295
Mailing Address - City:WEST LINN
Mailing Address - State:OR
Mailing Address - Zip Code:97068
Mailing Address - Country:US
Mailing Address - Phone:503-344-4378
Mailing Address - Fax:503-305-6782
Practice Address - Street 1:1750 BLANKENSHIP RD
Practice Address - Street 2:STE 295
Practice Address - City:WEST LINN
Practice Address - State:OR
Practice Address - Zip Code:97068-5101
Practice Address - Country:US
Practice Address - Phone:503-344-4378
Practice Address - Fax:503-334-3604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-01
Last Update Date:2015-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3663111N00000X
OR4107111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty