Provider Demographics
NPI:1689444960
Name:REVIVAL LLC
Entity Type:Organization
Organization Name:REVIVAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CNP
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:RIEHL
Authorized Official - Suffix:
Authorized Official - Credentials:CNP
Authorized Official - Phone:207-843-9591
Mailing Address - Street 1:51 FLETCHER RD
Mailing Address - Street 2:
Mailing Address - City:DOVER FOXCROFT
Mailing Address - State:ME
Mailing Address - Zip Code:04426-3715
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:139 STATE ST STE 2
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-5317
Practice Address - Country:US
Practice Address - Phone:207-843-9591
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-08
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty