Basic Information
| Provider Information | |||||||||
| NPI: | 1689114399 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RESTORE THERAPY SERVICES, LTD | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | RESTORE OUTPATIENT OF FLORALA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 245 CAHABA VALLEY PKWY | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | PELHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 351242216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2059426820 | ||||||||
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| Practice Location | |||||||||
| Address1: | 23621 GOLDENROD AVE | ||||||||
| Address2: | |||||||||
| City: | FLORALA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 364423652 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2059426820 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2017 | ||||||||
| LastUpdateDate: | 08/13/2020 | ||||||||
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| AuthorizedOfficialLastName: | KNOWLES | ||||||||
| AuthorizedOfficialFirstName: | DEBBIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2059426820 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | AL | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 11968 | 01 | AL | AL STATE BOARD OF HEALTH | OTHER | 011220 | 01 | AL | BCBS | OTHER |