Provider Demographics
NPI:1881210474
Name:RESTORE INCORPORATED
Entity Type:Organization
Organization Name:RESTORE INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE
Authorized Official - Prefix:
Authorized Official - First Name:SHELISSA
Authorized Official - Middle Name:F
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:CDC 1
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:907-374-1097
Mailing Address - Fax:907-374-1062
Practice Address - Street 1:1095 TENA AVE
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-1422
Practice Address - Country:US
Practice Address - Phone:907-374-1097
Practice Address - Fax:907-374-1062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-19
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilityGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1709994Medicaid