Healthcare Provider Details

I. General information

NPI: 1215522263
Provider Name (Legal Business Name): REVIVE RECOVERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2021
Last Update Date: 03/02/2021
Certification Date: 03/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3541 BONITA BAY BLVD STE 200
BONITA SPRINGS FL
34134-1703
US

IV. Provider business mailing address

3541 BONITA BAY BLVD STE 200
BONITA SPRINGS FL
34134-1703
US

V. Phone/Fax

Practice location:
  • Phone: 239-908-9958
  • Fax:
Mailing address:
  • Phone: 239-908-9958
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CHRISTINA THOMAS
Title or Position: OWNER
Credential:
Phone: 239-908-9958