Healthcare Provider Details

I. General information

NPI: 1255916987
Provider Name (Legal Business Name): REVIVE COMMUNITY HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2021
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 S MCCLINTOCK DR STE 140
TEMPE AZ
85282-7375
US

IV. Provider business mailing address

4700 S MCCLINTOCK DR STE 140
TEMPE AZ
85282-7375
US

V. Phone/Fax

Practice location:
  • Phone: 480-851-6309
  • Fax:
Mailing address:
  • Phone: 480-851-6309
  • Fax: 573-240-9791

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MICAH PHILLIPS
Title or Position: COO
Credential:
Phone: 602-717-8599