Healthcare Provider Details

I. General information

NPI: 1841003654
Provider Name (Legal Business Name): RESTORALIFE WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2025
Last Update Date: 01/28/2025
Certification Date: 01/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15808 CATERPILLAR DR
FONTANA CA
92336
US

IV. Provider business mailing address

PO BOX 976
RANCHO CUCAMONGA CA
91729-0976
US

V. Phone/Fax

Practice location:
  • Phone: 909-992-6315
  • Fax:
Mailing address:
  • Phone: 909-992-6315
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251X00000X
TaxonomySupports Brokerage Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARCUS RAMEY
Title or Position: FOUNDER/CEO
Credential:
Phone: 909-992-6315