Provider Demographics
NPI:1811631336
Name:REVIVED SENIOR LIVING
Entity Type:Organization
Organization Name:REVIVED SENIOR LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:IWUJI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-361-4187
Mailing Address - Street 1:7020 WILSON GROVE RD
Mailing Address - Street 2:
Mailing Address - City:MINT HILL
Mailing Address - State:NC
Mailing Address - Zip Code:28227-4352
Mailing Address - Country:US
Mailing Address - Phone:704-361-4187
Mailing Address - Fax:
Practice Address - Street 1:7020 WILSON GROVE RD
Practice Address - Street 2:
Practice Address - City:MINT HILL
Practice Address - State:NC
Practice Address - Zip Code:28227-4352
Practice Address - Country:US
Practice Address - Phone:704-361-4187
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-21
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1235885203Medicaid