Provider Demographics
NPI:1104453117
Name:REVITALIZED BEHAVIORAL HEALTHCARE, LLC
Entity type:Organization
Organization Name:REVITALIZED BEHAVIORAL HEALTHCARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:NANCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-346-5554
Mailing Address - Street 1:5577 AIRPORT HWY STE 102
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43615-7364
Mailing Address - Country:US
Mailing Address - Phone:419-214-1770
Mailing Address - Fax:
Practice Address - Street 1:5577 AIRPORT HWY STE 102
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43615-7364
Practice Address - Country:US
Practice Address - Phone:419-214-1770
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-27
Last Update Date:2020-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health