Provider Demographics
NPI:1700630050
Name:REVIVE RECOVERY NM
Entity type:Organization
Organization Name:REVIVE RECOVERY NM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:G
Authorized Official - Last Name:VIGIL
Authorized Official - Suffix:
Authorized Official - Credentials:LSAA
Authorized Official - Phone:505-785-4737
Mailing Address - Street 1:12309 CONEJO RD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87123-1517
Mailing Address - Country:US
Mailing Address - Phone:505-785-4737
Mailing Address - Fax:
Practice Address - Street 1:2325 SAN PEDRO DR NE STE 2A
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-4121
Practice Address - Country:US
Practice Address - Phone:505-785-4737
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-15
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty