Provider Demographics
NPI:1982428249
Name:REVITALIZE CHIROPRACTIC
Entity type:Organization
Organization Name:REVITALIZE CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:JULIET
Authorized Official - Middle Name:
Authorized Official - Last Name:EKEIWU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-680-1004
Mailing Address - Street 1:600 E BAILEY BOSWELL RD STE 150
Mailing Address - Street 2:
Mailing Address - City:FT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76131-3573
Mailing Address - Country:US
Mailing Address - Phone:817-482-3388
Mailing Address - Fax:817-704-0393
Practice Address - Street 1:600 E BAILEY BOSWELL RD STE 150
Practice Address - Street 2:
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76131-3573
Practice Address - Country:US
Practice Address - Phone:817-482-3388
Practice Address - Fax:817-704-0393
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-13
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty