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General NPI Number Information
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NPI Number | 1689444960
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Entity Type | Organization
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Legal Business Name | REVIVAL LLC
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Dates
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Enumeration Date | 01/08/2024
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Last Update Date | 01/08/2024
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Provider Practice Location Address
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Address Line | 139 STATE ST STE 2
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City | BANGOR
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State | ME
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Zip | 04401-5317
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Country | US
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Telephone | 207-843-9591
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Fax |
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Provider Business Mailing Address
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Address Line | 51 FLETCHER RD
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City | DOVER FOXCROFT
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State | ME
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Zip | 04426-3715
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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/CNP
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Name | STEPHANIE RIEHL
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Credential | CNP
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Telephone | 207-843-9591
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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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