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General NPI Number Information
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NPI Number | 1831566165
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Entity Type | Organization
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Legal Business Name | REVIVE CHIROPRACTIC & MED SPA, LLC
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Dates
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Enumeration Date | 08/21/2015
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Last Update Date | 10/02/2015
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Provider Practice Location Address
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Address Line | 494 W HILLSBORO BLVD
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City | DEERFIELD BEACH
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State | FL
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Zip | 33441-1604
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Country | US
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Telephone | 561-715-7956
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Fax |
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Provider Business Mailing Address
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Address Line | 494 W HILLSBORO BLVD
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City | DEERFIELD BEACH
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State | FL
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Zip | 33441-1604
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Country | US
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Telephone | 561-715-7956
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MARK RICHARDS
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Credential | D.C.
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Telephone | 561-715-7956
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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 | CH8257
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License Number State | FL
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