Provider Demographics
NPI:1568053734
Name:NEW REVIVE HOUSE, LLC
Entity Type:Organization
Organization Name:NEW REVIVE HOUSE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LUAMART
Authorized Official - Middle Name:
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-680-6797
Mailing Address - Street 1:44263 W. MCCLELLAND DRIVE
Mailing Address - Street 2:
Mailing Address - City:MARICOPA
Mailing Address - State:AZ
Mailing Address - Zip Code:85138
Mailing Address - Country:US
Mailing Address - Phone:623-264-5400
Mailing Address - Fax:623-264-5700
Practice Address - Street 1:44263 W. MCCLELLAND DRIVE
Practice Address - Street 2:
Practice Address - City:MARICOPA
Practice Address - State:AZ
Practice Address - Zip Code:85138
Practice Address - Country:US
Practice Address - Phone:623-264-5400
Practice Address - Fax:623-264-5700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-01
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility