=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245740216
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REVENANT CHIROPRACTIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/04/2017
-----------------------------------------------------
Last Update Date | 10/04/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20411 ROUTE 19 UNIT 6
-----------------------------------------------------
City | CRANBERRY TWP
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16066-7511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-799-2251
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20411 ROUTE 19 UNIT 6
-----------------------------------------------------
City | CRANBERRY TWP
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16066-7511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-799-2251
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE PROPRIETOR
-----------------------------------------------------
Name | DR. ERIC JOSEPH UBRIN
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 724-553-0600
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | DC011010
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------