Provider Demographics
NPI:1639513708
Name:RESTORE HEALTHCARE
Entity Type:Organization
Organization Name:RESTORE HEALTHCARE
Other - Org Name:RESTORE HEALTHCARE MEDICAL GROUP
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:JARRETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-559-9408
Mailing Address - Street 1:4258 HIGHWAY 49 S
Mailing Address - Street 2:UNIT 554
Mailing Address - City:HARRISBURG
Mailing Address - State:NC
Mailing Address - Zip Code:28075-0345
Mailing Address - Country:US
Mailing Address - Phone:704-559-9408
Mailing Address - Fax:704-731-0975
Practice Address - Street 1:4350 MAIN ST
Practice Address - Street 2:SUITE 211
Practice Address - City:HARRISBURG
Practice Address - State:NC
Practice Address - Zip Code:28075-7433
Practice Address - Country:US
Practice Address - Phone:704-559-9408
Practice Address - Fax:704-731-0975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-19
Last Update Date:2015-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 225100000X, 225X00000X, 235Z00000X
NC133VN1005X, 163WC0400X, 163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WC0400XNursing Service ProvidersRegistered NurseCase ManagementGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, RenalGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCREHABILITATIVEOtherBLUE CROSS BLUE SHIELD
NC=========Medicaid
NCREHABILITATIVEOtherBLUE CROSS BLUE SHIELD
NC=========OtherTRICARE
NC=========Medicare PIN