Provider Demographics
NPI:1023745908
Name:REVIVE RECOVERY
Entity type:Organization
Organization Name:REVIVE RECOVERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHERRYL
Authorized Official - Middle Name:
Authorized Official - Last Name:YORK
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:909-241-7555
Mailing Address - Street 1:2432 W BAY POINTE AVE
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-5038
Mailing Address - Country:US
Mailing Address - Phone:909-241-7555
Mailing Address - Fax:
Practice Address - Street 1:7894 MURPHY RD
Practice Address - Street 2:
Practice Address - City:MELBA
Practice Address - State:ID
Practice Address - Zip Code:83641-5167
Practice Address - Country:US
Practice Address - Phone:909-241-7555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-02
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)Group - Multi-Specialty
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction MedicineGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty