Provider Demographics
NPI:1245590918
Name:RESTORE THERAPY AND WELLNESS, INC.
Entity Type:Organization
Organization Name:RESTORE THERAPY AND WELLNESS, INC.
Other - Org Name:COASTAL FITNESS & REHABLILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:NICHOLAS
Authorized Official - Last Name:KOLMETZ
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:850-638-8447
Mailing Address - Street 1:877 THIRD STREET
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CHIPLEY
Mailing Address - State:FL
Mailing Address - Zip Code:32428
Mailing Address - Country:US
Mailing Address - Phone:850-638-8447
Mailing Address - Fax:850-638-9217
Practice Address - Street 1:877 THIRD STREET
Practice Address - Street 2:SUITE 1
Practice Address - City:CHIPLEY
Practice Address - State:FL
Practice Address - Zip Code:32428
Practice Address - Country:US
Practice Address - Phone:850-638-8447
Practice Address - Fax:850-638-9217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-29
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL686595Medicare Oscar/Certification