Provider Demographics
| NPI: | 1184120750 |
|---|---|
| Name: | RESTORE HEALTHCARE MEDICAL GROUP |
| Entity type: | Organization |
| Organization Name: | RESTORE HEALTHCARE MEDICAL GROUP |
| Other - Org Name: | <UNAVAIL> |
| Other - Org Type: | |
| Authorized Official - Title/Position: | EXECUTIVE DIRECTOR |
| Authorized Official - Prefix: | |
| Authorized Official - First Name: | CHRISTINA |
| Authorized Official - Middle Name: | |
| Authorized Official - Last Name: | JARRETT |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 704-559-9409 |
| Mailing Address - Street 1: | 2764 PLEASANT RD STE 10134 |
| Mailing Address - Street 2: | |
| Mailing Address - City: | FORT MILL |
| Mailing Address - State: | SC |
| Mailing Address - Zip Code: | 29708-7213 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 888-661-7730 |
| Mailing Address - Fax: | 888-813-2442 |
| Practice Address - Street 1: | 330 CAMP RD STE B43 |
| Practice Address - Street 2: | |
| Practice Address - City: | CHARLOTTE |
| Practice Address - State: | NC |
| Practice Address - Zip Code: | 28206-4005 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 888-661-7730 |
| Practice Address - Fax: | 888-813-2442 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2018-04-03 |
| Last Update Date: | 2021-10-28 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 101Y00000X | Behavioral Health & Social Service Providers | Counselor | Group - Multi-Specialty | |
| No | 171M00000X | Other Service Providers | Case Manager/Care Coordinator | Group - Multi-Specialty | |
| No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
| No | 224ZE0001X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant | Environmental Modification | Group - Multi-Specialty |
| No | 235Z00000X | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | Group - Multi-Specialty | |
| No | 251B00000X | Agencies | Case Management | Group - Multi-Specialty | |
| No | 251C00000X | Agencies | Day Training, Developmentally Disabled Services | ||
| No | 251S00000X | Agencies | Community/Behavioral Health | ||
| No | 252Y00000X | Agencies | Early Intervention Provider Agency | ||
| No | 253Z00000X | Agencies | In Home Supportive Care | ||
| No | 261QD1600X | Ambulatory Health Care Facilities | Clinic/Center | Developmental Disabilities | |
| No | 261QP2000X | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy | |
| No | 261QR0400X | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation | Group - Multi-Specialty |
| No | 261QX0100X | Ambulatory Health Care Facilities | Clinic/Center | Occupational Medicine | |
| No | 385HR2060X | Respite Care Facility | Respite Care | Respite Care, Intellectual and/or Developmental Disabilities, Child | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| NC | ========= | Medicaid | |
| SC | ========= | Medicaid | |
| ========= | Other | MANAGED CARE PROVIDER INSURANCE |
