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General NPI Number Information
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NPI Number | 1225681653
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Entity Type | Organization
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Legal Business Name | CHIROSPA REVIVE
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Dates
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Enumeration Date | 07/24/2019
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Last Update Date | 07/24/2019
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Provider Practice Location Address
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Address Line | 9896 BISSONNET ST STE 133
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City | HOUSTON
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State | TX
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Zip | 77036-8104
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Country | US
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Telephone | 240-779-1203
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Fax |
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Provider Business Mailing Address
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Address Line | 5512 RIO ALAMO ST
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City | ROSHARON
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State | TX
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Zip | 77583-4002
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Country | US
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Telephone | 240-779-1203
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. ALICIA BORNE-NUSOM
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Credential | DC
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Telephone | 240-779-1203
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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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