Provider Demographics
NPI:1295312288
Name:RESTORE HEALTH FAMILY PRACTICE
Entity type:Organization
Organization Name:RESTORE HEALTH FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:ALEATHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:WARE
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:719-292-5051
Mailing Address - Street 1:1235 LAKE PLAZA DR STE 220
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-3556
Mailing Address - Country:US
Mailing Address - Phone:719-292-5051
Mailing Address - Fax:719-306-0183
Practice Address - Street 1:1235 LAKE PLAZA DR STE 220
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-3556
Practice Address - Country:US
Practice Address - Phone:719-292-5051
Practice Address - Fax:719-306-0183
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-25
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO91224560Medicaid