Provider Demographics
NPI:1013755412
Name:REVIVE-
Entity type:Organization
Organization Name:REVIVE-
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LAFREDDRIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:HANNIBLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-510-3784
Mailing Address - Street 1:4029 N 72ND ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53216-1033
Mailing Address - Country:US
Mailing Address - Phone:262-510-3784
Mailing Address - Fax:
Practice Address - Street 1:9450 PINECROFT DR
Practice Address - Street 2:
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77380-3220
Practice Address - Country:US
Practice Address - Phone:262-510-3784
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-18
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343800000XTransportation ServicesSecured Medical Transport (VAN)