Provider Demographics
NPI:1477340735
Name:REVIVAL REENTRY
Entity type:Organization
Organization Name:REVIVAL REENTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-376-5086
Mailing Address - Street 1:521 CAPPS LN
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-7227
Mailing Address - Country:US
Mailing Address - Phone:707-376-5086
Mailing Address - Fax:
Practice Address - Street 1:521 CAPPS LN
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-7227
Practice Address - Country:US
Practice Address - Phone:707-376-5086
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-04-21
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable
No253Z00000XAgenciesIn Home Supportive Care
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
No251300000XAgenciesLocal Education Agency (LEA)
No174200000XOther Service ProvidersMeals
No177F00000XOther Service ProvidersLodging