Provider Demographics
NPI:1417530593
Name:LIFERESTORE MD USA NC1 LLC
Entity Type:Organization
Organization Name:LIFERESTORE MD USA NC1 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:BOB
Authorized Official - Middle Name:
Authorized Official - Last Name:OLOVSSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-494-8121
Mailing Address - Street 1:3910 GASTON AVE STE 140
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246-1523
Mailing Address - Country:US
Mailing Address - Phone:214-494-8121
Mailing Address - Fax:
Practice Address - Street 1:1427 MILITARY CUTOFF RD STE 140
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-3692
Practice Address - Country:US
Practice Address - Phone:214-494-8121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-05
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty