Provider Demographics
NPI:1821432634
Name:RESTORE HOUSE INC
Entity Type:Organization
Organization Name:RESTORE HOUSE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:GREER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-760-4209
Mailing Address - Street 1:1001 MISSISSIPPI AVE NW
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-4534
Mailing Address - Country:US
Mailing Address - Phone:218-444-9102
Mailing Address - Fax:
Practice Address - Street 1:1001 MISSISSIPPI AVE NW
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-4534
Practice Address - Country:US
Practice Address - Phone:218-444-9102
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-23
Last Update Date:2013-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1065889324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility