Provider Demographics
NPI:1184042236
Name:REVIVE HEALTH CENTER OF UTAH LLC
Entity Type:Organization
Organization Name:REVIVE HEALTH CENTER OF UTAH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:TIPPETTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-820-6585
Mailing Address - Street 1:3080 N FAIRFIELD RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-8694
Mailing Address - Country:US
Mailing Address - Phone:801-820-6585
Mailing Address - Fax:
Practice Address - Street 1:3080 N FAIRFIELD RD
Practice Address - Street 2:SUITE 1
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-8694
Practice Address - Country:US
Practice Address - Phone:801-820-6585
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-04
Last Update Date:2014-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1851542872164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Multi-Specialty