MEDICARE: REVIVE HOUSING LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	320800000X	Mental Illness Community Based Residential Treatment Facility
2	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility
3	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1083237986
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REVIVE HOUSING LLC

Provider Business Mailing Address
First Line	:	323 N MAIN ST
Second Line	:
City	:	SALISBURY
State	:	NC
Zip	:	28144-4301
Country	:	US
Telephone Number	:	281-217-7857
Fax Number	:	704-519-2708

Provider Business Practice Location Address
First Line	:	523 N LONG ST
Second Line	:
City	:	SALISBURY
State	:	NC
Zip	:	28144-4429
Country	:	US
Telephone Number	:	281-217-7857
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. DANIEL YOUNG
Credential	:
Telephone Number	:	281-217-7857

Provider Enumeration Date	:	05/26/2020
Last Update Date	:	11/30/2023

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