Provider Demographics
NPI:1720520851
Name:RESTORING LIVES, PERSONAL CARE AGENCY LLC
Entity Type:Organization
Organization Name:RESTORING LIVES, PERSONAL CARE AGENCY LLC
Other - Org Name:RESTORING LIVES, PERSONAL CARE AGENCY LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER / ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:L
Authorized Official - Last Name:BENNETT-CRITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-944-8354
Mailing Address - Street 1:2829 PERRY ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53713-3292
Mailing Address - Country:US
Mailing Address - Phone:608-709-5330
Mailing Address - Fax:608-709-5330
Practice Address - Street 1:2829 PERRY
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53713-3292
Practice Address - Country:US
Practice Address - Phone:608-709-5330
Practice Address - Fax:608-709-5330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-07
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care