Provider Demographics
NPI:1043558976
Name:RESTIVO, EDMOND J JR (CPO)
Entity Type:Individual
Prefix:MR
First Name:EDMOND
Middle Name:J
Last Name:RESTIVO
Suffix:JR
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3456 SPRING HILL AVE STE 19
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36608-1523
Mailing Address - Country:US
Mailing Address - Phone:251-605-2529
Mailing Address - Fax:
Practice Address - Street 1:3456 SPRING HILL AVE STE 19
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36608-1523
Practice Address - Country:US
Practice Address - Phone:251-605-2529
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-28
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA331216298335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA331216298OtherTAX