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General NPI Number Information
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NPI Number | 1710682729
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Entity Type | Organization
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Legal Business Name | REVIVE INJURY AND REHAB
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Dates
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Enumeration Date | 03/31/2023
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Last Update Date | 03/31/2023
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Provider Practice Location Address
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Address Line | 2313 W ARKANSAS LN STE 102
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City | PANTEGO
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State | TX
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Zip | 76013-6034
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Country | US
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Telephone | 817-642-5032
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Fax |
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Provider Business Mailing Address
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Address Line | 2313 W ARKANSAS LN STE 102
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City | PANTEGO
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State | TX
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Zip | 76013-6034
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Country | US
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Telephone | 817-642-5032
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Fax |
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Authorized Official
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Title or Position | DOCTOR OF CHIROPRACTIC
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Name | DJORN BAIN
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Credential | DC
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Telephone | 817-642-5032
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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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