Reva Health Autism Center LLC

Primary specialty

Clinic/CenterTaxonomy code 261Q00000X

Legal business name

REVA HEALTH AUTISM CENTER LLC

Practice address

880 Moore Lake Dr W
Fridley, MN 55432-6905

Phone

(763) 245-3686

NPI assigned

May 14, 2024

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Andrea Sampson

Title

Owner

Phone

(763) 245-3686

Specialties & licenses 1

Addresses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1715644800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1715644800000",
    "number": "1417706243",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "880 MOORE LAKE DR W",
            "city": "FRIDLEY",
            "state": "MN",
            "postal_code": "554326905"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "880 MOORE LAKE DR W",
            "city": "FRIDLEY",
            "state": "MN",
            "postal_code": "554326905",
            "telephone_number": "763-245-3686"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "REVA HEALTH AUTISM CENTER LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2024-05-14",
        "last_updated": "2024-05-14",
        "certification_date": "2024-05-14",
        "status": "A",
        "authorized_official_last_name": "SAMPSON",
        "authorized_official_first_name": "ANDREA",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "763-245-3686"
    },
    "taxonomies": [
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Clinic/Center in Fridley, MN
• Providers in Fridley, MN by specialty
• Clinic/Center in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 14, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.