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General NPI Number Information
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NPI Number | 1285202143
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Entity Type | Organization
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Legal Business Name | REVIVE CHIROPRACTIC LLC
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Dates
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Enumeration Date | 06/16/2021
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Last Update Date | 11/11/2021
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Provider Practice Location Address
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Address Line | 107 S HARDING ST
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City | OWEN
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State | WI
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Zip | 54460-9737
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Country | US
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Telephone | 715-229-0262
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 99
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City | OWEN
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State | WI
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Zip | 54460-0099
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Country | US
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Telephone | 715-229-0262
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Fax |
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Authorized Official
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Title or Position | OWNER/AO
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Name | DR. ADAM JOSHUA CARR
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Credential | DC
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Telephone | 978-851-0515
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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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