Provider Demographics
NPI:1801139019
Name:RESTORE INTERVENTIONAL SPINE & SPORTS MEDICINE LLC
Entity type:Organization
Organization Name:RESTORE INTERVENTIONAL SPINE & SPORTS MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / CEO
Authorized Official - Prefix:
Authorized Official - First Name:RAHUL
Authorized Official - Middle Name:NAVEN
Authorized Official - Last Name:DESAI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-535-8302
Mailing Address - Street 1:9925 SW NIMBUS AVE.
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97008
Mailing Address - Country:US
Mailing Address - Phone:503-535-8302
Mailing Address - Fax:503-416-8732
Practice Address - Street 1:9925 SW NIMBUS AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97008
Practice Address - Country:US
Practice Address - Phone:503-535-8302
Practice Address - Fax:503-416-8732
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-05
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD284442085R0204X
ORDO1507522081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty