Provider Demographics
NPI:1508333477
Name:ORANGE COUNTY REVIVE SERVICES, INC.
Entity Type:Organization
Organization Name:ORANGE COUNTY REVIVE SERVICES, INC.
Other - Org Name:OC REVIVE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:
Authorized Official - Last Name:MICHAELIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-606-4681
Mailing Address - Street 1:24432 MUIRLANDS BLVD STE 221
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-3951
Mailing Address - Country:US
Mailing Address - Phone:949-510-3358
Mailing Address - Fax:
Practice Address - Street 1:24432 MUIRLANDS BLVD STE 221
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-3951
Practice Address - Country:US
Practice Address - Phone:949-510-3358
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-30
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health