Healthcare Provider Details

I. General information

NPI: 1083237986
Provider Name (Legal Business Name): REVIVE HOUSING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2020
Last Update Date: 11/30/2023
Certification Date: 01/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

523 N LONG ST
SALISBURY NC
28144-4429
US

IV. Provider business mailing address

323 N MAIN ST
SALISBURY NC
28144-4301
US

V. Phone/Fax

Practice location:
  • Phone: 281-217-7857
  • Fax:
Mailing address:
  • Phone: 281-217-7857
  • Fax: 704-519-2708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. DANIEL YOUNG
Title or Position: OWNER
Credential:
Phone: 281-217-7857