Provider Demographics
NPI:1396244471
Name:REVIVE WELLNESS AND CHIROPRACTIC CENTER
Entity type:Organization
Organization Name:REVIVE WELLNESS AND CHIROPRACTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:BAADE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:319-333-1299
Mailing Address - Street 1:890 GROUSE LN
Mailing Address - Street 2:
Mailing Address - City:NORTH LIBERTY
Mailing Address - State:IA
Mailing Address - Zip Code:52317-4855
Mailing Address - Country:US
Mailing Address - Phone:319-621-6238
Mailing Address - Fax:
Practice Address - Street 1:808 5TH ST
Practice Address - Street 2:
Practice Address - City:CORALVILLE
Practice Address - State:IA
Practice Address - Zip Code:52241-2321
Practice Address - Country:US
Practice Address - Phone:319-333-1299
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-05
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA085133111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty