Provider Demographics
NPI:1366207425
Name:REVIVE RECOVERY AND WELLNESS
Entity type:Organization
Organization Name:REVIVE RECOVERY AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:DEPUGH
Authorized Official - Suffix:
Authorized Official - Credentials:CNP
Authorized Official - Phone:740-708-5019
Mailing Address - Street 1:1886 BLAIN HWY
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:OH
Mailing Address - Zip Code:45690-9070
Mailing Address - Country:US
Mailing Address - Phone:740-708-5019
Mailing Address - Fax:
Practice Address - Street 1:1886 BLAIN HWY
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:OH
Practice Address - Zip Code:45690-9070
Practice Address - Country:US
Practice Address - Phone:740-708-5019
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-19
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center