Provider Demographics
NPI:1508496258
Name:RESTORED TO NEW LIFE SERVICES, LLC
Entity Type:Organization
Organization Name:RESTORED TO NEW LIFE SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JOHNNY
Authorized Official - Middle Name:RANDLE
Authorized Official - Last Name:RAY
Authorized Official - Suffix:JR
Authorized Official - Credentials:LCSW-PIP, LAC, QMPH
Authorized Official - Phone:605-271-7712
Mailing Address - Street 1:1915 E 8TH ST STE 102
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57103-1865
Mailing Address - Country:US
Mailing Address - Phone:605-271-7712
Mailing Address - Fax:605-274-1557
Practice Address - Street 1:225 E 11TH ST STE 206
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57104-6482
Practice Address - Country:US
Practice Address - Phone:605-271-7712
Practice Address - Fax:605-274-1557
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-22
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health