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General NPI Number Information
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NPI Number | 1508333477
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Entity Type | Organization
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Legal Business Name | ORANGE COUNTY REVIVE SERVICES, INC.
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Dates
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Enumeration Date | 10/30/2018
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Last Update Date | 09/30/2019
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Provider Practice Location Address
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Address Line | 24432 MUIRLANDS BLVD STE 221
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City | LAKE FOREST
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State | CA
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Zip | 92630-3951
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Country | US
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Telephone | 949-510-3358
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Fax |
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Provider Business Mailing Address
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Address Line | 24432 MUIRLANDS BLVD STE 221
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City | LAKE FOREST
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State | CA
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Zip | 92630-3951
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Country | US
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Telephone | 949-510-3358
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | TYLER MICHAELIS
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Credential |
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Telephone | 949-606-4681
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health 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 | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number |
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License Number State |
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