Provider Demographics
NPI:1538967377
Name:WATTS WORLD REVIVAL
Entity type:Organization
Organization Name:WATTS WORLD REVIVAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RICKEY
Authorized Official - Middle Name:A
Authorized Official - Last Name:HODGES
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:310-256-6605
Mailing Address - Street 1:11328 S CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90059-1642
Mailing Address - Country:US
Mailing Address - Phone:323-569-4162
Mailing Address - Fax:
Practice Address - Street 1:11328 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90059-1642
Practice Address - Country:US
Practice Address - Phone:323-569-4162
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-06
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health