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General NPI Number Information
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NPI Number | 1952698680
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Entity Type | Organization
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Legal Business Name | REVIVE INJURY AND WELLNESS, PC
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Dates
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Enumeration Date | 07/01/2011
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Last Update Date | 06/02/2015
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Provider Practice Location Address
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Address Line | 1750 BLANKENSHIP RD STE 295
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City | WEST LINN
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State | OR
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Zip | 97068-5101
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Country | US
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Telephone | 503-344-4378
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Fax | 503-334-3604
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Provider Business Mailing Address
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Address Line | 1750 BLANKENSHIP RD SUITE 295
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City | WEST LINN
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State | OR
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Zip | 97068
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Country | US
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Telephone | 503-344-4378
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Fax | 503-305-6782
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. ERIN DANIELLE BLOOM
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Credential | DC
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Telephone | 503-344-4378
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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 | 4107
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License Number State | OR
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Taxonomy #2
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 3663
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License Number State | OR
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