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General NPI Number Information
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NPI Number | 1003601220
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Entity Type | Organization
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Legal Business Name | REVIVE BEHAVIORAL HEALTH, LLC
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Dates
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Enumeration Date | 04/09/2025
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Last Update Date | 04/10/2025
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Provider Practice Location Address
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Address Line | 206 S MULBERRY ST STE A
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City | MOUNT VERNON
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State | OH
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Zip | 43050-3331
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Country | US
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Telephone | 740-501-4836
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Fax |
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Provider Business Mailing Address
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Address Line | 6130 SHARP RD
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City | MOUNT VERNON
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State | OH
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Zip | 43050-9477
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JORDAN R MOORE
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Credential | APRN-CNP
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Telephone | 740-501-4836
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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