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General NPI Number Information
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NPI Number | 1083326706
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Entity Type | Organization
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Legal Business Name | RESEREVELATIONS, LLC
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Dates
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Enumeration Date | 12/14/2022
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Last Update Date | 01/05/2025
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Provider Practice Location Address
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Address Line | 31 S MAIN ST
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City | DAYTON
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State | OH
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Zip | 45402-2070
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Country | US
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Telephone | 937-860-1038
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Fax | 270-203-0587
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Provider Business Mailing Address
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Address Line | 31 S MAIN ST
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City | DAYTON
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State | OH
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Zip | 45402-2070
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Country | US
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Telephone | 937-860-1038
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Fax | 270-203-0587
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Authorized Official
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Title or Position | CEO, OWNER & DIRECTOR
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Name | MR. DE'RESE ZYIRE GOODEN
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Credential | NCC, LCMHC, CCHT
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Telephone | 937-860-1038
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 251C00000X
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Taxonomy Name | Developmentally Disabled Services Day Training Agency
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License Number |
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Taxonomy #3
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Taxonomy Code | 251K00000X
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Taxonomy Name | Public Health or Welfare Agency
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Taxonomy #4
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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Taxonomy #5
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Taxonomy Code | 253Z00000X
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Taxonomy Name | In Home Supportive Care Agency
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License Number |
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Taxonomy #6
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Taxonomy Code | 347C00000X
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Taxonomy Name | Private Vehicle
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License Number |
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Taxonomy #7
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Taxonomy Code | 372500000X
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Taxonomy Name | Chore Provider
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License Number |
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Taxonomy #8
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Taxonomy Code | 251V00000X
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Taxonomy Name | Voluntary or Charitable Agency
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License Number |
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