Organization
REVIVAL REENTRY
Active
Organization subpart
No
Provider details
NPI number
Authorized official
ASHLEY ELLIOTT (PRESIDENT/CEO)
(707) 376-5086
Entity
Organization
Contact information
Practice address
521 CAPPS LN, UKIAH, CA 95482-7227
(707) 376-5086
Mailing address
521 CAPPS LN, UKIAH, CA 95482-7227
(707) 376-5086
Taxonomy
Speciality
Code
Description
License number
State
174200000X
Meals Provider
—
—
177F00000X
Lodging Provider
—
—
251300000X
Local Education Agency (LEA)
—
—
251B00000X
Case Management Agency
—
—
251S00000X
Community/Behavioral Health Agency
—
—
251V00000X
Voluntary or Charitable Agency
Primary
—
—
253Z00000X
In Home Supportive Care Agency
—
—
Other
Enumeration date
04/21/2025
Last updated
04/21/2025
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