Provider Demographics
NPI:1891370185
Name:REVIVE MINISTRIES INC
Entity Type:Organization
Organization Name:REVIVE MINISTRIES INC
Other - Org Name:REVIVE LIFE HOUSE OUTPATIENT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-354-9841
Mailing Address - Street 1:800 S. MAIN STREET
Mailing Address - Street 2:SUITE C.
Mailing Address - City:NICHOLASVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40356-1868
Mailing Address - Country:US
Mailing Address - Phone:859-241-5174
Mailing Address - Fax:859-305-6004
Practice Address - Street 1:800 S. MAIN STREET
Practice Address - Street 2:SUITE C.
Practice Address - City:NICHOLASVILLE
Practice Address - State:KY
Practice Address - Zip Code:40356-1868
Practice Address - Country:US
Practice Address - Phone:859-241-5174
Practice Address - Fax:859-305-6004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-17
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)Group - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100737830Medicaid