Provider Demographics
NPI:1255176061
Name:RESTORATION WOUNDCARE MEDICAL GROUP, P.A.
Entity type:Organization
Organization Name:RESTORATION WOUNDCARE MEDICAL GROUP, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF ADMINISTRATIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JANA
Authorized Official - Middle Name:
Authorized Official - Last Name:HULL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-930-1000
Mailing Address - Street 1:2139 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-5768
Mailing Address - Country:US
Mailing Address - Phone:208-930-1000
Mailing Address - Fax:877-376-4040
Practice Address - Street 1:2139 N MAIN ST
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-5768
Practice Address - Country:US
Practice Address - Phone:208-930-1000
Practice Address - Fax:877-376-4040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-25
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty