Healthcare Provider Details

I. General information

NPI: 1093621211
Provider Name (Legal Business Name): REVIVE HOME ASSISTANCE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2026
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32784 RYAN RD
WARREN MI
48092-1112
US

IV. Provider business mailing address

4568 FORESTVIEW DR
WEST BLOOMFIELD MI
48322-4509
US

V. Phone/Fax

Practice location:
  • Phone: 248-789-3535
  • Fax:
Mailing address:
  • Phone: 248-789-3535
  • Fax: 248-789-3535

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: VARDEN BAHOURA
Title or Position: MEMBER
Credential:
Phone: 248-789-3535