Provider Demographics
NPI:1164173555
Name:CENTER FOR RESTORATIVE MEDICINE LLC
Entity Type:Organization
Organization Name:CENTER FOR RESTORATIVE MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:DITTBRENDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-467-1697
Mailing Address - Street 1:275 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53085-3315
Mailing Address - Country:US
Mailing Address - Phone:920-467-1697
Mailing Address - Fax:
Practice Address - Street 1:275 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN FALLS
Practice Address - State:WI
Practice Address - Zip Code:53085-3315
Practice Address - Country:US
Practice Address - Phone:920-467-1697
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-17
Last Update Date:2022-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty