Healthcare Provider Details

I. General information

NPI: 1548086440
Provider Name (Legal Business Name): REVIVE COMMUNITY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/25/2024
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18930 GROVER ST
OMAHA NE
68130-6089
US

IV. Provider business mailing address

18930 GROVER ST
OMAHA NE
68130-6089
US

V. Phone/Fax

Practice location:
  • Phone: 866-426-1877
  • Fax:
Mailing address:
  • Phone: 866-426-1877
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number StateNULL

VIII. Authorized Official

Name: JLYNN DARAE HARTZELL
Title or Position: CEO
Credential:
Phone: 402-320-3057