Provider Demographics
NPI:1851856983
Name:RESTORE 3:16, LLC
Entity Type:Organization
Organization Name:RESTORE 3:16, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:DELFANITA
Authorized Official - Middle Name:ELLEN
Authorized Official - Last Name:WARREN
Authorized Official - Suffix:
Authorized Official - Credentials:HAIR LOSS SPECIALIST
Authorized Official - Phone:708-316-1630
Mailing Address - Street 1:430 E 162ND ST STE 474
Mailing Address - Street 2:
Mailing Address - City:SOUTH HOLLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60473-2258
Mailing Address - Country:US
Mailing Address - Phone:708-316-1630
Mailing Address - Fax:
Practice Address - Street 1:16060 OAK PARK AVE STE 110
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-1626
Practice Address - Country:US
Practice Address - Phone:708-360-1630
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-02
Last Update Date:2019-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Multi-Specialty