Provider Demographics
NPI:1639570567
Name:RESTORATION FOR LIFE
Entity Type:Organization
Organization Name:RESTORATION FOR LIFE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LATAMERIA
Authorized Official - Middle Name:DONTA
Authorized Official - Last Name:MCNAIR
Authorized Official - Suffix:
Authorized Official - Credentials:EVANGELIST
Authorized Official - Phone:336-895-6128
Mailing Address - Street 1:2301 W MEADOWVIEW RD STE 110
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27407-3704
Mailing Address - Country:US
Mailing Address - Phone:336-895-6128
Mailing Address - Fax:
Practice Address - Street 1:2301 W MEADOWVIEW RD STE 110
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27407-3704
Practice Address - Country:US
Practice Address - Phone:336-895-6128
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-10
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty