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General NPI Number Information
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NPI Number | 1568286862
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Entity Type | Organization
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Legal Business Name | REVIVE CHIROPRACTIC AND WELLNESS, PLLC
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Dates
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Enumeration Date | 11/13/2024
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Last Update Date | 11/13/2024
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Provider Practice Location Address
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Address Line | 1740 US-411 UNIT 1
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City | VONORE
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State | TN
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Zip | 37885
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Country | US
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Telephone | 423-420-7111
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Fax |
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Provider Business Mailing Address
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Address Line | 115 WARBLER CT
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City | VONORE
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State | TN
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Zip | 37885-2046
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Country | US
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Telephone | 865-368-6295
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | LUKE WIGGINS
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Credential | DC
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Telephone | 865-368-6295
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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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