Healthcare Provider Details

I. General information

NPI: 1700630050
Provider Name (Legal Business Name): REVIVE RECOVERY NM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2024
Last Update Date: 04/15/2024
Certification Date: 04/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2325 SAN PEDRO DR NE STE 2A
ALBUQUERQUE NM
87110-4121
US

IV. Provider business mailing address

12309 CONEJO RD NE
ALBUQUERQUE NM
87123-1517
US

V. Phone/Fax

Practice location:
  • Phone: 505-785-4737
  • Fax:
Mailing address:
  • Phone: 505-785-4737
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name: JOSEPH G VIGIL
Title or Position: OWNER
Credential: LSAA
Phone: 505-785-4737