Provider Demographics
NPI:1013705698
Name:J-REVIVAL LLC
Entity type:Organization
Organization Name:J-REVIVAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JEWELL
Authorized Official - Middle Name:
Authorized Official - Last Name:REICHENBERGER
Authorized Official - Suffix:
Authorized Official - Credentials:MED
Authorized Official - Phone:689-242-0854
Mailing Address - Street 1:4391 GARDEN TRL
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55123-1756
Mailing Address - Country:US
Mailing Address - Phone:689-242-0854
Mailing Address - Fax:
Practice Address - Street 1:4391 GARDEN TRL
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55123-1756
Practice Address - Country:US
Practice Address - Phone:689-242-0854
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-04-25
Last Update Date:2025-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care