Provider Demographics
NPI:1174226757
Name:RESTORATION CLINIC
Entity type:Organization
Organization Name:RESTORATION CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ENGLISH
Authorized Official - Middle Name:PAIGE
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:423-334-2300
Mailing Address - Street 1:16850 STATE HIGHWAY 58 S STE A
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:TN
Mailing Address - Zip Code:37322-5259
Mailing Address - Country:US
Mailing Address - Phone:423-507-7961
Mailing Address - Fax:423-454-0125
Practice Address - Street 1:16850 STATE HIGHWAY 58 SOUTH
Practice Address - Street 2:SUITE A
Practice Address - City:DECATUR
Practice Address - State:TN
Practice Address - Zip Code:37322
Practice Address - Country:US
Practice Address - Phone:423-506-3781
Practice Address - Fax:423-454-0125
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RESTORATION CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-03-23
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care