Provider Demographics
NPI:1063909067
Name:REVIVE MINISTRIES INC
Entity type:Organization
Organization Name:REVIVE MINISTRIES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-354-9841
Mailing Address - Street 1:800 S MAIN STREET
Mailing Address - Street 2:SUITE C
Mailing Address - City:NICHOLASVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40356-1868
Mailing Address - Country:US
Mailing Address - Phone:859-241-5174
Mailing Address - Fax:859-305-6004
Practice Address - Street 1:111 COCONUT GROVE DRIVE
Practice Address - Street 2:
Practice Address - City:NICHOLASVILLE
Practice Address - State:KY
Practice Address - Zip Code:40356-2321
Practice Address - Country:US
Practice Address - Phone:859-881-4505
Practice Address - Fax:859-241-1483
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-16
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilityGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100649290Medicaid
KY7100541540OtherMEDICAID GROUP
KY810626OtherBHSO