Provider Demographics
NPI:1134943988
Name:REVIVE AID, LLC
Entity type:Organization
Organization Name:REVIVE AID, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NOAH
Authorized Official - Middle Name:MANCINI
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-933-7718
Mailing Address - Street 1:4202 FREIGHT ST
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-2506
Mailing Address - Country:US
Mailing Address - Phone:817-933-7718
Mailing Address - Fax:
Practice Address - Street 1:318 CIRCUIT LN
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23608-4913
Practice Address - Country:US
Practice Address - Phone:817-933-7718
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-08
Last Update Date:2024-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty