MEDICARE: REVIVE PREMIER RECOVERY INC.

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	324500000X	Substance Abuse Rehabilitation Facility

General Provider Information

NPI Number	:	1427749910
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REVIVE PREMIER RECOVERY INC.

Provider Business Mailing Address
First Line	:	3630 POTOSI AVE
Second Line	:
City	:	STUDIO CITY
State	:	CA
Zip	:	91604-4059
Country	:	US
Telephone Number	:	559-201-3337
Fax Number	:

Provider Business Practice Location Address
First Line	:	3630 POTOSI AVE
Second Line	:
City	:	STUDIO CITY
State	:	CA
Zip	:	91604-4059
Country	:	US
Telephone Number	:	559-201-3337
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. KRISTOPHER FRONTELLA
Credential	:
Telephone Number	:	559-201-3337

Provider Enumeration Date	:	05/16/2023
Last Update Date	:	05/17/2023

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