Provider Demographics
NPI:1568700763
Name:RESTORE PT & WELLNESS
Entity Type:Organization
Organization Name:RESTORE PT & WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:HORTON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:703-402-8536
Mailing Address - Street 1:44927 GEORGE WASHINGTON BLVD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20147-4295
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:44927 GEORGE WASHINGTON BLVD
Practice Address - Street 2:SUITE 210
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20147-4295
Practice Address - Country:US
Practice Address - Phone:571-291-9936
Practice Address - Fax:571-918-4935
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-22
Last Update Date:2013-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305203754261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy