1184120750 NPI number — RESTORE HEALTHCARE MEDICAL GROUP

Table of content: THERESA ROSA NICHOLE CALHOUN (NPI 1013507409)

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)