Provider Demographics
NPI:1760822662
Name:RESTORE OF ARIZONA
Entity Type:Organization
Organization Name:RESTORE OF ARIZONA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:BODE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-209-5067
Mailing Address - Street 1:17431 N 71ST DR
Mailing Address - Street 2:SUITE 104
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-8598
Mailing Address - Country:US
Mailing Address - Phone:623-209-5067
Mailing Address - Fax:623-209-5065
Practice Address - Street 1:17431 N 71ST DR
Practice Address - Street 2:SUITE 104
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-8598
Practice Address - Country:US
Practice Address - Phone:623-209-5067
Practice Address - Fax:623-209-5065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-25
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty