Healthcare Provider Details

I. General information

NPI: 1962117440
Provider Name (Legal Business Name): REVIVE PATHWAY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2023
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1240 BROADWAY
EL CAJON CA
92021-4994
US

IV. Provider business mailing address

6650 GUNPARK DR
BOULDER CO
80301-7002
US

V. Phone/Fax

Practice location:
  • Phone: 619-841-1310
  • Fax:
Mailing address:
  • Phone: 619-841-1310
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JUDSON LEA
Title or Position: COO
Credential:
Phone: 619-841-1310