Healthcare Provider Details

I. General information

NPI: 1336730217
Provider Name (Legal Business Name): REVIVE HEALTH AND CHIROPRACTIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2021
Last Update Date: 02/02/2021
Certification Date: 02/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

891 W BAXTER DR
SOUTH JORDAN UT
84095-8506
US

IV. Provider business mailing address

891 W BAXTER DR
SOUTH JORDAN UT
84095-8506
US

V. Phone/Fax

Practice location:
  • Phone: 509-270-3687
  • Fax:
Mailing address:
  • Phone: 509-270-3687
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. KYLE ROBERT GORDON
Title or Position: OWNER
Credential: DC
Phone: 801-899-9605