Provider Demographics
NPI:1629460456
Name:RESTORE OUTREACH CENTER
Entity Type:Organization
Organization Name:RESTORE OUTREACH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:KNIGHTSHEAD
Authorized Official - Suffix:
Authorized Official - Credentials:ETC
Authorized Official - Phone:225-937-3189
Mailing Address - Street 1:2415 GOVERNMENT ST
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-5318
Mailing Address - Country:US
Mailing Address - Phone:225-388-5265
Mailing Address - Fax:225-388-5869
Practice Address - Street 1:2415 GOVERNMENT ST
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-5318
Practice Address - Country:US
Practice Address - Phone:225-388-5265
Practice Address - Fax:225-388-5869
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RESTORE OUTREACH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-03-03
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)