=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902495070
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REBELUTION CHIROPRACTIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/13/2021
-----------------------------------------------------
Last Update Date | 01/13/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4800 WHITESBURG DR SW # 30-192
-----------------------------------------------------
City | HUNTSVILLE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35802-1698
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-805-0570
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4800 WHITESBURG DR SW # 30-192
-----------------------------------------------------
City | HUNTSVILLE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35802-1698
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-805-0570
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MOLLIE A ROOD
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 408-805-0570
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------