Provider Demographics
NPI:1104650316
Name:REVIVE CHIROPRACTIC AND WELLNESS CENTER PLLC
Entity type:Organization
Organization Name:REVIVE CHIROPRACTIC AND WELLNESS CENTER PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:VADER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:360-953-3567
Mailing Address - Street 1:15306 NE 19TH ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-2811
Mailing Address - Country:US
Mailing Address - Phone:360-953-3567
Mailing Address - Fax:
Practice Address - Street 1:6923 NW FRIBERG STRUNK ST STE 135
Practice Address - Street 2:
Practice Address - City:CAMAS
Practice Address - State:WA
Practice Address - Zip Code:98607-7796
Practice Address - Country:US
Practice Address - Phone:360-953-3567
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-29
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty