Provider Demographics
NPI:1235673963
Name:RESTORATIVE RESIDENTIAL LLC
Entity Type:Organization
Organization Name:RESTORATIVE RESIDENTIAL LLC
Other - Org Name:LIGHTFULLY BEHAVIORAL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF REVENUE
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-728-9093
Mailing Address - Street 1:PO BOX 969
Mailing Address - Street 2:
Mailing Address - City:HOLLY SPRINGS
Mailing Address - State:NC
Mailing Address - Zip Code:27540-0969
Mailing Address - Country:US
Mailing Address - Phone:916-352-7997
Mailing Address - Fax:916-352-7997
Practice Address - Street 1:1414 SAN VICENTE BLVD
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90402-2204
Practice Address - Country:US
Practice Address - Phone:885-762-8088
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-14
Last Update Date:2022-10-13
Deactivation Date:2017-11-22
Deactivation Code:
Reactivation Date:2018-03-15
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness