MEDICARE: REVIVAL MENTAL HEALTH 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	320800000X	Mental Illness Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1588435325
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REVIVAL MENTAL HEALTH LLC

Provider Business Mailing Address
First Line	:	16252 MAGELLAN LN
Second Line	:
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92647-3525
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	16252 MAGELLAN LN
Second Line	:
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92647-3525
Country	:	US
Telephone Number	:	949-776-9476
Fax Number	:

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	TYLER MICHAELIS
Credential	:
Telephone Number	:	949-606-4681

Provider Enumeration Date	:	01/10/2024
Last Update Date	:	01/10/2024

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