Provider Demographics
NPI:1790381929
Name:RESTORE INCORPORATED
Entity Type:Organization
Organization Name:RESTORE INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:M
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:CDC1, PCC
Authorized Official - Phone:907-374-1097
Mailing Address - Street 1:PO BOX 73004
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99707-3004
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1088 TAZLINA CT
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-1421
Practice Address - Country:US
Practice Address - Phone:907-374-1097
Practice Address - Fax:907-374-1062
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-12-11
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1712403Medicaid