Provider Demographics
NPI:1649646969
Name:REVIVE SPORT & SPINE
Entity type:Organization
Organization Name:REVIVE SPORT & SPINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:J
Authorized Official - Last Name:REHEISSE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:801-944-1855
Mailing Address - Street 1:7351 S UNION PARK AVE STE 150
Mailing Address - Street 2:
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047-1869
Mailing Address - Country:US
Mailing Address - Phone:801-944-1855
Mailing Address - Fax:385-351-5950
Practice Address - Street 1:7351 S UNION PARK AVE STE 150
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-1869
Practice Address - Country:US
Practice Address - Phone:801-944-1855
Practice Address - Fax:385-351-5950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-20
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT91235421202111N00000X, 111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU000087534Medicare PIN