| Revive 180 Llc | |
|
10071 Crescent Rd Potosi MO 63664-2040 | |
| (573) 438-9800 | |
| (573) 240-9916 |
| Full Name | Revive 180 Llc |
|---|---|
| Speciality | Counselor - Professional |
| Location | 10071 Crescent Rd, Potosi, Missouri |
| Authorized Official Name and Position | Christy L Pashia (PROFESSIONAL COUNSELOR/OWNER) |
| Authorized Official Contact | 5734389800 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Revive 180 Llc 10071 Crescent Rd Potosi MO 63664-2040 Ph: (573) 438-9800 | Revive 180 Llc 10071 Crescent Rd Potosi MO 63664-2040 Ph: (573) 438-9800 |
| NPI Number | 1568197556 |
|---|---|
| Provider Enumeration Date | 07/22/2022 |
| Last Update Date | 12/11/2022 |
| Certification Date | 12/11/2022 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1568197556 | NPI | - | NPPES |
| 490084654 | Medicaid | MO |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 101YP2500X | Counselor - Professional | (* (Not Available)) | Primary |
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