Provider Demographics
NPI:1114439346
Name:RESTORATION CENTER CHICAGO
Entity Type:Organization
Organization Name:RESTORATION CENTER CHICAGO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:LUSSIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-549-9051
Mailing Address - Street 1:1200 W 35TH ST STE 5B5220
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60609-1305
Mailing Address - Country:US
Mailing Address - Phone:312-548-9051
Mailing Address - Fax:
Practice Address - Street 1:1200 W 35TH ST STE 5B5220
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60609-1305
Practice Address - Country:US
Practice Address - Phone:312-548-9051
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-27
Last Update Date:2017-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)