=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982428249
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REVITALIZE CHIROPRACTIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/13/2024
-----------------------------------------------------
Last Update Date | 11/13/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 600 E BAILEY BOSWELL RD STE 150
-----------------------------------------------------
City | FT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76131-3573
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-482-3388
-----------------------------------------------------
Fax | 817-704-0393
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 600 E BAILEY BOSWELL RD STE 150
-----------------------------------------------------
City | FT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76131-3573
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-482-3388
-----------------------------------------------------
Fax | 817-704-0393
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING
-----------------------------------------------------
Name | JULIET EKEIWU
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 404-680-1004
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------