MEDICARE: REVOLVE RECOVERY, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)
2	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1548997539
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REVOLVE RECOVERY, INC

Provider Business Mailing Address
First Line	:	1732 AVIATION BLVD STE 317
Second Line	:
City	:	REDONDO BEACH
State	:	CA
Zip	:	90278-2810
Country	:	US
Telephone Number	:	323-253-3047
Fax Number	:

Provider Business Practice Location Address
First Line	:	3101 WASHINGTON BLVD
Second Line	:
City	:	MARINA DEL REY
State	:	CA
Zip	:	90292-5571
Country	:	US
Telephone Number	:	323-253-3047
Fax Number	:

Authorized Official
Title or Position	:	COMPLIANCE OFFICER
Name	:	JONATHAN AUSTIN
Credential	:
Telephone Number	:	818-915-5668

Provider Enumeration Date	:	08/01/2022
Last Update Date	:	08/01/2022

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