Healthcare Provider Details

I. General information

NPI: 1932979754
Provider Name (Legal Business Name): REVIVE MINISTRIES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2024
Last Update Date: 01/03/2024
Certification Date: 01/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 S 2ND ST
NICHOLASVILLE KY
40356-1553
US

IV. Provider business mailing address

800 S MAIN ST STE C
NICHOLASVILLE KY
40356-1868
US

V. Phone/Fax

Practice location:
  • Phone: 859-241-3892
  • Fax:
Mailing address:
  • Phone: 859-241-3892
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: TODD M JOHNS
Title or Position: ADMIN
Credential:
Phone: 859-881-4505