MEDICARE: REVIVED MINDS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1033832324
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REVIVED MINDS LLC

Provider Business Mailing Address
First Line	:	6212 W CHARLESTON BLVD # 14
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-1163
Country	:	US
Telephone Number	:	818-232-6452
Fax Number	:

Provider Business Practice Location Address
First Line	:	6212 W CHARLESTON BLVD # 14
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-1163
Country	:	US
Telephone Number	:	818-232-6452
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	TISTO CHAPMAN JR.
Credential	:
Telephone Number	:	818-232-6452

Provider Enumeration Date	:	09/21/2022
Last Update Date	:	04/10/2024

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