Provider Demographics
NPI:1558835843
Name:RESTORED LIVING INC
Entity Type:Organization
Organization Name:RESTORED LIVING INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:OKPENZE
Authorized Official - Middle Name:
Authorized Official - Last Name:BALLARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-378-2269
Mailing Address - Street 1:3044 CALIFORNIA AVENUE
Mailing Address - Street 2:
Mailing Address - City:PARKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21234-4141
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3044 CALIFORNIA AVENUE
Practice Address - Street 2:
Practice Address - City:PARKVILLE
Practice Address - State:MD
Practice Address - Zip Code:21234-4141
Practice Address - Country:US
Practice Address - Phone:917-378-2269
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-20
Last Update Date:2019-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health