Healthcare Provider Details

I. General information

NPI: 1427480797
Provider Name (Legal Business Name): REVELATION WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2013
Last Update Date: 08/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

316 E DOUGLAS ST
ONEILL NE
68763-1830
US

IV. Provider business mailing address

316 E DOUGLAS ST
ONEILL NE
68763-1830
US

V. Phone/Fax

Practice location:
  • Phone: 402-336-7133
  • Fax: 877-207-3713
Mailing address:
  • Phone: 402-336-7133
  • Fax: 877-207-3713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1630
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number2629
License Number StateNE

VIII. Authorized Official

Name: TRENT SHOEMAKER
Title or Position: OWNER / CHIROPRACTOR
Credential: DC
Phone: 402-336-7133