=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003530502
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REVIVE HEALTH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/28/2022
-----------------------------------------------------
Last Update Date | 09/28/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13715 OAKLANDS MANOR DR
-----------------------------------------------------
City | LAUREL
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20708-1430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-945-8482
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13715 OAKLANDS MANOR DR
-----------------------------------------------------
City | LAUREL
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20708-1430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-945-8482
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MARIA TANCHO
-----------------------------------------------------
Credential | CRNP
-----------------------------------------------------
Telephone | 443-945-8482
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 364SP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Clinical Nurse Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------