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General NPI Number Information
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NPI Number | 1073385597
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Entity Type | Organization
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Legal Business Name | REVIVE FAMILY CHIROPRACTIC LLC
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Dates
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Enumeration Date | 10/27/2023
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Last Update Date | 12/07/2023
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Provider Practice Location Address
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Address Line | 1203 N MILFORD RD
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City | MILFORD
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State | MI
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Zip | 48381-1033
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Country | US
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Telephone | 248-714-6127
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Fax | 248-714-6128
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Provider Business Mailing Address
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Address Line | 306 S ALP ST
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City | BAY CITY
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State | MI
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Zip | 48706-4271
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Country | US
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Telephone | 575-207-5757
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | SHAWNEE MANGINO
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Credential | DC
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Telephone | 575-207-5757
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number |
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License Number State |
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