Healthcare Provider Details

I. General information

NPI: 1841144912
Provider Name (Legal Business Name): REVIVAL HOUSING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2026
Last Update Date: 02/24/2026
Certification Date: 02/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 BELVIDERE ST W
WEST ST PAUL MN
55118-5717
US

IV. Provider business mailing address

438 DALY ST
SAINT PAUL MN
55102-3550
US

V. Phone/Fax

Practice location:
  • Phone: 952-239-6790
  • Fax:
Mailing address:
  • Phone: 952-239-6790
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: LAWRENCE TAN
Title or Position: CFO
Credential:
Phone: 651-338-8512