Provider Demographics
NPI:1922542075
Name:LIFERESTORE MD USA LLC
Entity Type:Organization
Organization Name:LIFERESTORE MD USA LLC
Other - Org Name:RESTOREDOC MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BOB
Authorized Official - Middle Name:
Authorized Official - Last Name:OLOVSSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-955-8695
Mailing Address - Street 1:3910 GASTON AVE STE 140
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246-1523
Mailing Address - Country:US
Mailing Address - Phone:214-494-8121
Mailing Address - Fax:
Practice Address - Street 1:3910 GASTON AVE STE 140
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-1523
Practice Address - Country:US
Practice Address - Phone:214-494-8121
Practice Address - Fax:972-707-0702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-08
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1922542075OtherNPI