Healthcare Provider Details

I. General information

NPI: 1699293852
Provider Name (Legal Business Name): REVIVE RECOVERY INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2017
Last Update Date: 09/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

263 MAIN ST
NASHUA NH
03060-2936
US

IV. Provider business mailing address

77 NORTHEASTERN BLVD STE C
NASHUA NH
03062-3128
US

V. Phone/Fax

Practice location:
  • Phone: 603-793-2884
  • Fax:
Mailing address:
  • Phone: 603-882-3616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR0800X
TaxonomyRecovery Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JESSICA KEARNS
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 603-882-3616