MEDICARE: REVIVE MINISTRIES 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	2084A0401X	Addiction Medicine (Psychiatry & Neurology) Physician

General Provider Information

NPI Number	:	1932979754
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REVIVE MINISTRIES INC

Provider Business Mailing Address
First Line	:	800 S MAIN ST STE C
Second Line	:
City	:	NICHOLASVILLE
State	:	KY
Zip	:	40356-1868
Country	:	US
Telephone Number	:	859-241-3892
Fax Number	:

Provider Business Practice Location Address
First Line	:	104 S 2ND ST
Second Line	:
City	:	NICHOLASVILLE
State	:	KY
Zip	:	40356-1553
Country	:	US
Telephone Number	:	859-241-3892
Fax Number	:

Authorized Official
Title or Position	:	ADMIN
Name	:	TODD M JOHNS
Credential	:
Telephone Number	:	859-881-4505

Provider Enumeration Date	:	01/03/2024
Last Update Date	:	01/03/2024

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Directions to “REVIVE MINISTRIES INC ” Practice Location

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