Provider Demographics
NPI:1427012335
Name:RESTORE PHYSICAL THERAPY
Entity Type:Organization
Organization Name:RESTORE PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:L
Authorized Official - Last Name:LAUSENG
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:605-275-4125
Mailing Address - Street 1:4925 E 26TH ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57110-6950
Mailing Address - Country:US
Mailing Address - Phone:605-275-4125
Mailing Address - Fax:605-332-6616
Practice Address - Street 1:4925 E 26TH ST
Practice Address - Street 2:SUITE B
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57110-6950
Practice Address - Country:US
Practice Address - Phone:605-275-4125
Practice Address - Fax:605-332-6616
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1178225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD4995060OtherBCBS NUMBER
SD5833562Medicaid
SD5833562Medicaid