Provider Demographics
NPI:1447584388
Name:PLACE OF RESTORATION
Entity Type:Organization
Organization Name:PLACE OF RESTORATION
Other - Org Name:THE LORD'S TABLE
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:OLUMIDE
Authorized Official - Middle Name:
Authorized Official - Last Name:OLUWOLE
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:773-392-1585
Mailing Address - Street 1:4332 N KEDZIE AVE
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-1302
Mailing Address - Country:US
Mailing Address - Phone:773-267-5008
Mailing Address - Fax:
Practice Address - Street 1:4332 N KEDZIE AVE
Practice Address - Street 2:1ST FLOOR
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-1302
Practice Address - Country:US
Practice Address - Phone:773-267-5008
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE LORD'S TABLE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-09-24
Last Update Date:2009-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)