Provider Demographics
NPI:1083421564
Name:RELIFE PRO CORPORATION
Entity type:Organization
Organization Name:RELIFE PRO CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:PROVALENKO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-992-9966
Mailing Address - Street 1:9716 REDSTONE DR
Mailing Address - Street 2:
Mailing Address - City:INDIAN LAND
Mailing Address - State:SC
Mailing Address - Zip Code:29707-5406
Mailing Address - Country:US
Mailing Address - Phone:803-992-9966
Mailing Address - Fax:
Practice Address - Street 1:9716 REDSTONE DR
Practice Address - Street 2:
Practice Address - City:INDIAN LAND
Practice Address - State:SC
Practice Address - Zip Code:29707-5406
Practice Address - Country:US
Practice Address - Phone:803-992-9966
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-17
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty