Provider Demographics
NPI:1184354946
Name:REVIVE PREMIER TREATMENT CENTER
Entity type:Organization
Organization Name:REVIVE PREMIER TREATMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:FRONTELLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:559-201-3337
Mailing Address - Street 1:13111 VENTURA BLVD
Mailing Address - Street 2:
Mailing Address - City:STUDIO CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91604-2218
Mailing Address - Country:US
Mailing Address - Phone:559-201-3337
Mailing Address - Fax:
Practice Address - Street 1:13111 VENTURA BLVD
Practice Address - Street 2:
Practice Address - City:STUDIO CITY
Practice Address - State:CA
Practice Address - Zip Code:91604-2218
Practice Address - Country:US
Practice Address - Phone:559-201-3337
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-14
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No251S00000XAgenciesCommunity/Behavioral Health