Provider Demographics
NPI:1376030262
Name:REVIVE MINISTRIES, INC
Entity Type:Organization
Organization Name:REVIVE MINISTRIES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:A
Authorized Official - Last Name:TOMLIAN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, LCADC
Authorized Official - Phone:859-576-8279
Mailing Address - Street 1:185 ELM TREE LN
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40507-1924
Mailing Address - Country:US
Mailing Address - Phone:859-576-8279
Mailing Address - Fax:859-881-0045
Practice Address - Street 1:185 ELM TREE LN
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40507
Practice Address - Country:US
Practice Address - Phone:859-469-9023
Practice Address - Fax:859-881-0045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-17
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilityGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY810626OtherBHSO
KY710052080Medicaid