Provider Demographics
NPI:1306460266
Name:REVIVE F W
Entity type:Organization
Organization Name:REVIVE F W
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-417-9092
Mailing Address - Street 1:10907 MARTINDALE RD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77048-2011
Mailing Address - Country:US
Mailing Address - Phone:713-417-9092
Mailing Address - Fax:
Practice Address - Street 1:10907 MARTINDALE RD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77048-2011
Practice Address - Country:US
Practice Address - Phone:713-417-9092
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-05
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility