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General NPI Number Information
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NPI Number | 1366207425
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Entity Type | Organization
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Legal Business Name | REVIVE RECOVERY AND WELLNESS
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Dates
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Enumeration Date | 02/19/2024
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Last Update Date | 02/19/2024
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Provider Practice Location Address
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Address Line | 1886 BLAIN HWY
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City | WAVERLY
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State | OH
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Zip | 45690-9070
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Country | US
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Telephone | 740-708-5019
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Fax |
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Provider Business Mailing Address
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Address Line | 1886 BLAIN HWY
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City | WAVERLY
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State | OH
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Zip | 45690-9070
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Country | US
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Telephone | 740-708-5019
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DEANNA DEPUGH
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Credential | CNP
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Telephone | 740-708-5019
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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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 | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number |
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License Number State |
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