Provider Demographics
NPI:1043917396
Name:RESTORE WELLNESS PLLC
Entity type:Organization
Organization Name:RESTORE WELLNESS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BETH
Authorized Official - Middle Name:
Authorized Official - Last Name:RAYHILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-810-8961
Mailing Address - Street 1:4207 JEFFERS DR
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47150-9312
Mailing Address - Country:US
Mailing Address - Phone:502-810-8961
Mailing Address - Fax:
Practice Address - Street 1:105 DAVENTRY LN STE 205
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40223-3874
Practice Address - Country:US
Practice Address - Phone:502-810-8961
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-07
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
00000OtherNA