Provider Demographics
NPI:1245048388
Name:RIVER SAGE REVIVAL
Entity type:Organization
Organization Name:RIVER SAGE REVIVAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VETERAN COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-614-1157
Mailing Address - Street 1:PO BOX 1
Mailing Address - Street 2:
Mailing Address - City:LAKE ISABELLA
Mailing Address - State:CA
Mailing Address - Zip Code:93240-0001
Mailing Address - Country:US
Mailing Address - Phone:760-614-1157
Mailing Address - Fax:
Practice Address - Street 1:4005 ERSKINE CREEK RD
Practice Address - Street 2:
Practice Address - City:LAKE ISABELLA
Practice Address - State:CA
Practice Address - Zip Code:93240-9585
Practice Address - Country:US
Practice Address - Phone:760-614-1157
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-20
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No251B00000XAgenciesCase Management
No251V00000XAgenciesVoluntary or Charitable
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health