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General NPI Number Information
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NPI Number | 1477340735
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Entity Type | Organization
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Legal Business Name | REVIVAL REENTRY
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Dates
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Enumeration Date | 04/21/2025
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Last Update Date | 04/21/2025
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Provider Practice Location Address
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Address Line | 521 CAPPS LN
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City | UKIAH
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State | CA
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Zip | 95482-7227
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Country | US
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Telephone | 707-376-5086
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Fax |
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Provider Business Mailing Address
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Address Line | 521 CAPPS LN
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City | UKIAH
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State | CA
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Zip | 95482-7227
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Country | US
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Telephone | 707-376-5086
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Fax |
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Authorized Official
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Title or Position | PRESIDENT/CEO
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Name | ASHLEY ELLIOTT
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Credential |
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Telephone | 707-376-5086
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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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License Number State |
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Taxonomy #2
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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 #3
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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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License Number State |
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Taxonomy #4
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Taxonomy Code | 251300000X
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Taxonomy Name | Local Education Agency (LEA)
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 174200000X
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Taxonomy Name | Meals Provider
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 177F00000X
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Taxonomy Name | Lodging Provider
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License Number |
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License Number State |
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Taxonomy #7
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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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License Number State |
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