Provider Demographics
NPI:1740975721
Name:REVIVE OUTREACH, INC.
Entity type:Organization
Organization Name:REVIVE OUTREACH, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMAAL
Authorized Official - Middle Name:
Authorized Official - Last Name:REED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-565-6486
Mailing Address - Street 1:1480 WOODSTONE DR STE 103
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63304-6872
Mailing Address - Country:US
Mailing Address - Phone:314-565-6486
Mailing Address - Fax:
Practice Address - Street 1:5738 PAMPLIN PL
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136-4918
Practice Address - Country:US
Practice Address - Phone:314-565-6486
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-06
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities