Provider Demographics
NPI:1801388558
Name:BIORESTORE LLC
Entity Type:Organization
Organization Name:BIORESTORE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:G
Authorized Official - Last Name:MARSTELLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-578-1220
Mailing Address - Street 1:914 RANCH RD
Mailing Address - Street 2:
Mailing Address - City:CONNERSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47331-1238
Mailing Address - Country:US
Mailing Address - Phone:317-578-1220
Mailing Address - Fax:833-228-1102
Practice Address - Street 1:10967 ALLISONVILLE RD STE 220
Practice Address - Street 2:
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46038
Practice Address - Country:US
Practice Address - Phone:317-578-1220
Practice Address - Fax:833-228-1102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-30
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01068656A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty