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General NPI Number Information
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NPI Number | 1396244471
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Entity Type | Organization
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Legal Business Name | REVIVE WELLNESS AND CHIROPRACTIC CENTER
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Dates
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Enumeration Date | 02/05/2018
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Last Update Date | 02/05/2018
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Provider Practice Location Address
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Address Line | 808 5TH ST
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City | CORALVILLE
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State | IA
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Zip | 52241-2321
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Country | US
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Telephone | 319-333-1299
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Fax |
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Provider Business Mailing Address
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Address Line | 890 GROUSE LN
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City | NORTH LIBERTY
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State | IA
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Zip | 52317-4855
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Country | US
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Telephone | 319-621-6238
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Fax |
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Authorized Official
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Title or Position | CHIROPRACTOR
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Name | DR. TINA BAADE
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Credential | D.C.
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Telephone | 319-333-1299
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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 | 085133
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License Number State | IA
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