Provider Demographics
NPI:1629454327
Name:MEDILOGIC LLC
Entity Type:Organization
Organization Name:MEDILOGIC LLC
Other - Org Name:RESTORATION MEDICAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:HILL
Authorized Official - Last Name:WORKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-991-1006
Mailing Address - Street 1:406 SE 131ST AVE STE 109
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-4031
Mailing Address - Country:US
Mailing Address - Phone:541-991-1006
Mailing Address - Fax:360-326-2271
Practice Address - Street 1:406 SE 131ST AVE
Practice Address - Street 2:SUITE 109
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-4004
Practice Address - Country:US
Practice Address - Phone:541-991-1006
Practice Address - Fax:360-326-2271
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-04
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP60159597261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA500634349Medicaid
WAG8894629Medicare PIN
WA7558590001Medicare NSC