Provider Demographics
NPI:1891895496
Name:RESTORE PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:RESTORE PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:OLIVER
Authorized Official - Middle Name:C
Authorized Official - Last Name:PATALINGHUG
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:248-608-3149
Mailing Address - Street 1:61 W HAMLIN RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48307-3835
Mailing Address - Country:US
Mailing Address - Phone:248-608-3149
Mailing Address - Fax:248-608-3149
Practice Address - Street 1:2370 WALTON BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48309-1471
Practice Address - Country:US
Practice Address - Phone:248-608-3149
Practice Address - Fax:248-608-3149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-24
Last Update Date:2009-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501005647225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP00341360OtherRAILROAD MEDICARE
MI024298OtherMIDWEST
MIP300380001OtherHAP
MI65-0-E0-1648-0OtherBCBS
MI024298OtherMIDWEST
MI=========OtherPPOM
MIP00341360OtherRAILROAD MEDICARE
MI=========OtherMOLINA
MIP300380001OtherHAP
MI=========Medicaid