Healthcare Provider Details

I. General information

NPI: 1396452611
Provider Name (Legal Business Name): RESTORE VASCULAR PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2022
Last Update Date: 08/29/2023
Certification Date: 08/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18510 E SAN TAN BLVD STE 115
QUEEN CREEK AZ
85142-2206
US

IV. Provider business mailing address

18510 E SAN TAN BLVD STE 115
QUEEN CREEK AZ
85142-2206
US

V. Phone/Fax

Practice location:
  • Phone: 480-442-3990
  • Fax:
Mailing address:
  • Phone: 480-442-3990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: NATHAN IAN WELLER
Title or Position: OWNER
Credential:
Phone: 480-874-6808