1487158440 NPI number — REVIVE HOME HEALTH CARE LLC

Table of content: (NPI 1487158440)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487158440 NPI number — REVIVE HOME HEALTH CARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
REVIVE HOME HEALTH CARE LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1487158440
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/27/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
210 N 17TH ST STE 102A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63103-2518
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-449-1060
Provider Business Mailing Address Fax Number:
314-669-9921

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10174 W FLORISSANT AVE STE 331
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63136-2104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-449-1060
Provider Business Practice Location Address Fax Number:
314-754-8306
Provider Enumeration Date:
03/22/2018

Additional Information

Authorized Official

Authorized Official Last Name:
FLEMON
Authorized Official First Name:
LATONYA
Authorized Official Middle Name:
D
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
314-449-1060

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 253Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1487158440 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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