Healthcare Provider Details

I. General information

NPI: 1063909067
Provider Name (Legal Business Name): REVIVE MINISTRIES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2018
Last Update Date: 11/23/2022
Certification Date: 11/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 COCONUT GROVE DRIVE
NICHOLASVILLE KY
40356-2321
US

IV. Provider business mailing address

800 S MAIN STREET SUITE C
NICHOLASVILLE KY
40356-1868
US

V. Phone/Fax

Practice location:
  • Phone: 859-881-4505
  • Fax: 859-241-1483
Mailing address:
  • Phone: 859-241-5174
  • Fax: 859-305-6004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: TODD JOHNS
Title or Position: CEO
Credential:
Phone: 859-354-9841