Provider Demographics
NPI:1063036424
Name:RESTORER OF YOUTH AND FAMILIES LLC
Entity Type:Organization
Organization Name:RESTORER OF YOUTH AND FAMILIES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMIN
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:BAINES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-852-4695
Mailing Address - Street 1:5553 S PEORIA AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74105-6840
Mailing Address - Country:US
Mailing Address - Phone:918-852-4695
Mailing Address - Fax:918-205-9036
Practice Address - Street 1:1831 E 71ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-3922
Practice Address - Country:US
Practice Address - Phone:918-852-4695
Practice Address - Fax:918-205-9036
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RESTORER OF YOUTH AND FAMILIES LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-06-02
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health