=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437528023
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REVIVE CHIROPRACTIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/24/2015
-----------------------------------------------------
Last Update Date | 01/17/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7825 N OAK TRFY
-----------------------------------------------------
City | KANSAS CITY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64118-1426
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-272-3580
-----------------------------------------------------
Fax | 816-256-2714
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7825 N OAK TRFY
-----------------------------------------------------
City | KANSAS CITY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64118-1426
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-272-3580
-----------------------------------------------------
Fax | 816-256-2714
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR
-----------------------------------------------------
Name | FRANK P SIRAGUSO
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 816-272-3580
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 2015000688
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------