Provider Demographics
NPI:1164132908
Name:REVIVE INTEGRATED CARE SERVICES LLC
Entity Type:Organization
Organization Name:REVIVE INTEGRATED CARE SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:TAMALA
Authorized Official - Middle Name:LASHAWN
Authorized Official - Last Name:DANIELS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-688-6327
Mailing Address - Street 1:1616 E INDIAN SCHOOL RD STE 400
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-8604
Mailing Address - Country:US
Mailing Address - Phone:602-688-6327
Mailing Address - Fax:
Practice Address - Street 1:1616 E INDIAN SCHOOL RD STE 400
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-8604
Practice Address - Country:US
Practice Address - Phone:602-688-6327
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-02
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health