Healthcare Provider Details

I. General information

NPI: 1780192674
Provider Name (Legal Business Name): REVITALIZE CHIROPRACTIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2018
Last Update Date: 10/18/2021
Certification Date: 10/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

936 CHESTERFIELD PKWY E
CHESTERFIELD MO
63017-2042
US

IV. Provider business mailing address

936 CHESTERFIELD PKWY E
CHESTERFIELD MO
63017-2042
US

V. Phone/Fax

Practice location:
  • Phone: 636-537-0564
  • Fax: 314-775-9870
Mailing address:
  • Phone: 636-537-0564
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

Name: SAMANTHA CHRISTINE CHAPEL
Title or Position: OWNER
Credential: DC
Phone: 636-537-0564