Healthcare Provider Details

I. General information

NPI: 1407115934
Provider Name (Legal Business Name): REVOLUTION WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2012
Last Update Date: 02/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6011 BROADWAY ST 101
SAN ANTONIO TX
78209-4554
US

IV. Provider business mailing address

6011 BROADWAY ST 101
SAN ANTONIO TX
78209-4554
US

V. Phone/Fax

Practice location:
  • Phone: 210-771-2136
  • Fax: 210-247-9463
Mailing address:
  • Phone: 210-771-2136
  • Fax: 210-247-9463

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. LAUREN BROOKE DUARTE
Title or Position: DOCTOR
Credential: DC
Phone: 210-771-2136