Provider Demographics
NPI:1497424949
Name:RESTORE INCORPORTED
Entity Type:Organization
Organization Name:RESTORE INCORPORTED
Other - Org Name:REFINE DETOXIFICATION AND RECOVERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SHELISSA
Authorized Official - Middle Name:F
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-374-1097
Mailing Address - Street 1:PO BOX 73004
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99707-3004
Mailing Address - Country:US
Mailing Address - Phone:907-374-1097
Mailing Address - Fax:
Practice Address - Street 1:211 CUSHMAN ST
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-4639
Practice Address - Country:US
Practice Address - Phone:907-374-1097
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-08
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1687081Medicaid