Healthcare Provider Details

I. General information

NPI: 1023745908
Provider Name (Legal Business Name): REVIVE RECOVERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2022
Last Update Date: 08/02/2022
Certification Date: 08/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7894 MURPHY RD
MELBA ID
83641-5167
US

IV. Provider business mailing address

2432 W BAY POINTE AVE
NAMPA ID
83651-5038
US

V. Phone/Fax

Practice location:
  • Phone: 909-241-7555
  • Fax:
Mailing address:
  • Phone: 909-241-7555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State

VIII. Authorized Official

Name: SHERRYL YORK
Title or Position: OWNER
Credential: RN
Phone: 909-241-7555