Provider Demographics
NPI:1063771186
Name:REVIVE CHIROPRACTIC INC
Entity type:Organization
Organization Name:REVIVE CHIROPRACTIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHRINER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:269-599-5986
Mailing Address - Street 1:6604 ALBANY WOODS BLVD
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:OH
Mailing Address - Zip Code:43054-8649
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1258 E POWELL RD
Practice Address - Street 2:
Practice Address - City:LEWIS CENTER
Practice Address - State:OH
Practice Address - Zip Code:43035-8619
Practice Address - Country:US
Practice Address - Phone:614-781-8808
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-09
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4274111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty