MEDICARE: REVELATION CHIROPRACTIC LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	6674	CO

General Provider Information

NPI Number	:	1003199779
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REVELATION CHIROPRACTIC LLC

Provider Business Mailing Address
First Line	:	2721 S COLLEGE AVE UNIT 4A
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-2160
Country	:	US
Telephone Number	:	970-377-2250
Fax Number	:	970-377-2251

Provider Business Practice Location Address
First Line	:	2721 S COLLEGE AVE UNIT 4A
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-2160
Country	:	US
Telephone Number	:	970-377-2250
Fax Number	:	970-377-2251

Authorized Official
Title or Position	:	OWNER
Name	:	DR. CHAD MCMAHAN
Credential	:	D.C.
Telephone Number	:	970-377-2250

Provider Enumeration Date	:	09/20/2011
Last Update Date	:	09/20/2011

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