Provider Demographics
NPI:1003231820
Name:REVIVE DETOX CENTER
Entity Type:Organization
Organization Name:REVIVE DETOX CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RAFAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:772-828-6992
Mailing Address - Street 1:344 SW QUIET WOODS
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-8230
Mailing Address - Country:US
Mailing Address - Phone:772-828-6992
Mailing Address - Fax:
Practice Address - Street 1:8489 S FEDERAL HWY # 1
Practice Address - Street 2:(S. FEDERAL HIGHWAY) STE.16
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-3360
Practice Address - Country:US
Practice Address - Phone:772-828-6992
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-03
Last Update Date:2014-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility