Provider Demographics
NPI:1477185676
Name:RESTORE OUTREACH CENTER OHIO
Entity Type:Organization
Organization Name:RESTORE OUTREACH CENTER OHIO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:KNIGHTSHEAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-937-3189
Mailing Address - Street 1:4315 BLUEBONNET BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-9661
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3966 WARRENSVILLE CENTER RD
Practice Address - Street 2:
Practice Address - City:WARRENSVILLE HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44122-6770
Practice Address - Country:US
Practice Address - Phone:440-340-5086
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RESTORE OUTREACH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-02-06
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty