Provider Demographics
NPI:1093420135
Name:RESTORALIVE LLC
Entity Type:Organization
Organization Name:RESTORALIVE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DARRELL
Authorized Official - Middle Name:
Authorized Official - Last Name:NURSE
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:203-460-0665
Mailing Address - Street 1:19 SHERMAN CT
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-4303
Mailing Address - Country:US
Mailing Address - Phone:203-460-0665
Mailing Address - Fax:
Practice Address - Street 1:19 SHERMAN CT
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-4303
Practice Address - Country:US
Practice Address - Phone:203-460-0665
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-23
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty