Provider Demographics
NPI:1083326706
Name:RESEREVELATIONS, LLC
Entity type:Organization
Organization Name:RESEREVELATIONS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO, OWNER & DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DE'RESE
Authorized Official - Middle Name:ZYIRE
Authorized Official - Last Name:GOODEN
Authorized Official - Suffix:
Authorized Official - Credentials:NCC, LCMHC, CCHT
Authorized Official - Phone:937-860-1038
Mailing Address - Street 1:31 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45402-2070
Mailing Address - Country:US
Mailing Address - Phone:937-860-1038
Mailing Address - Fax:270-203-0587
Practice Address - Street 1:31 S MAIN ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45402-2070
Practice Address - Country:US
Practice Address - Phone:937-860-1038
Practice Address - Fax:270-203-0587
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-14
Last Update Date:2025-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable
No251B00000XAgenciesCase Management
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No251K00000XAgenciesPublic Health or Welfare
No251S00000XAgenciesCommunity/Behavioral Health
No253Z00000XAgenciesIn Home Supportive Care
No347C00000XTransportation ServicesPrivate Vehicle
No372500000XNursing Service Related ProvidersChore Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0307155Medicaid