MEDICARE: RESTORED TO NEW LIFE SERVICES, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1508496258
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RESTORED TO NEW LIFE SERVICES, LLC

Provider Business Mailing Address
First Line	:	1915 E 8TH ST STE 102
Second Line	:
City	:	SIOUX FALLS
State	:	SD
Zip	:	57103-1865
Country	:	US
Telephone Number	:	605-271-7712
Fax Number	:	605-274-1557

Provider Business Practice Location Address
First Line	:	225 E 11TH ST STE 206
Second Line	:
City	:	SIOUX FALLS
State	:	SD
Zip	:	57104-6482
Country	:	US
Telephone Number	:	605-271-7712
Fax Number	:	605-274-1557

Authorized Official
Title or Position	:	OWNER/THERAPIST
Name	:	JOHNNY RANDLE RAY JR.
Credential	:	LCSW-PIP, LAC, QMPH
Telephone Number	:	605-271-7712

Provider Enumeration Date	:	01/22/2020
Last Update Date	:	07/24/2023

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