Provider Demographics
NPI:1043597503
Name:RESTORE WELLNESS CENTER, S.C.
Entity Type:Organization
Organization Name:RESTORE WELLNESS CENTER, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:OUELLETTE
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:207-989-9008
Mailing Address - Street 1:41 ACME RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:BREWER
Mailing Address - State:ME
Mailing Address - Zip Code:04412-1543
Mailing Address - Country:US
Mailing Address - Phone:207-989-9008
Mailing Address - Fax:207-989-9007
Practice Address - Street 1:41 ACME RD
Practice Address - Street 2:SUITE 2
Practice Address - City:BREWER
Practice Address - State:ME
Practice Address - Zip Code:04412-1543
Practice Address - Country:US
Practice Address - Phone:207-989-9008
Practice Address - Fax:207-989-9007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-12
Last Update Date:2011-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAP081148363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty