Provider Demographics
NPI:1184398331
Name:REVIVAL RECOVERY CENTER STAFFING LLC
Entity type:Organization
Organization Name:REVIVAL RECOVERY CENTER STAFFING LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER, AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:A
Authorized Official - Last Name:PERNA
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:248-949-7177
Mailing Address - Street 1:208 W HIGHLAND RD STE 102
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48357-4574
Mailing Address - Country:US
Mailing Address - Phone:833-773-8482
Mailing Address - Fax:810-775-0303
Practice Address - Street 1:208 W HIGHLAND RD STE 102
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:MI
Practice Address - Zip Code:48357-4574
Practice Address - Country:US
Practice Address - Phone:833-773-8482
Practice Address - Fax:810-775-0303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-02
Last Update Date:2025-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty