Healthcare Provider Details

I. General information

NPI: 1063615094
Provider Name (Legal Business Name): REVELLO CHIROPRACTIC DC SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2007
Last Update Date: 08/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14406 JOHN HUMPHREY DR
ORLAND PARK IL
60462-2638
US

IV. Provider business mailing address

14406 JOHN HUMPHREY DR
ORLAND PARK IL
60462-2638
US

V. Phone/Fax

Practice location:
  • Phone: 708-364-0638
  • Fax: 708-364-9805
Mailing address:
  • Phone: 708-364-0638
  • Fax: 708-364-9805

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number
License Number StateIL

VIII. Authorized Official

Name: DR. JOHN W. REVELLO
Title or Position: OWNER
Credential: D.C.
Phone: 708-364-0638