1184120750 NPI number — RESTORE HEALTHCARE MEDICAL GROUP

Table of content: (NPI 1184120750)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184120750 NPI number — RESTORE HEALTHCARE MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RESTORE HEALTHCARE MEDICAL GROUP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
RESTORE HEALTHCARE PEDIATRIC THERAPY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184120750
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/16/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2764 PLEASANT RD STE 10909
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT MILL
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29708-7213
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-661-7730
Provider Business Mailing Address Fax Number:
877-831-0055

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 WAXHAW PROFESSIONAL PARK DRIVE
Provider Second Line Business Practice Location Address:
STE 105 F
Provider Business Practice Location Address City Name:
WAXHAW
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28173
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
888-661-7730
Provider Business Practice Location Address Fax Number:
877-831-0055
Provider Enumeration Date:
04/03/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
JARRETT
Authorized Official First Name:
CHRISTINA
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
704-559-9409

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251C00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 253Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QD1600X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QP2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QX0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 385HR2060X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 252Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)