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General NPI Number Information
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NPI Number | 1922721083
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Entity Type | Organization
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Legal Business Name | REVIVAL MENTAL HEALTH LLC
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Dates
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Enumeration Date | 09/23/2022
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Last Update Date | 01/10/2024
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Provider Practice Location Address
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Address Line | 9879 HAMILTON AVE
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City | FOUNTAIN VALLEY
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State | CA
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Zip | 92708-5117
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Country | US
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Telephone | 949-606-4681
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Fax |
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Provider Business Mailing Address
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Address Line | 9879 HAMILTON AVE
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City | FOUNTAIN VALLEY
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State | CA
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Zip | 92708-5117
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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 | MANAGING MEMBER
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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 | 320800000X
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Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
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License Number |
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License Number State |
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