Healthcare Provider Details

I. General information

NPI: 1235673963
Provider Name (Legal Business Name): RESTORATIVE RESIDENTIAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2016
Last Update Date: 10/23/2025
Certification Date: 10/23/2025
Deactivation Date: 11/22/2017
Reactivation Date: 03/15/2018

III. Provider practice location address

1414 SAN VICENTE BLVD
SANTA MONICA CA
90402-2204
US

IV. Provider business mailing address

PO BOX 45991
SAN FRANCISCO CA
94145-0991
US

V. Phone/Fax

Practice location:
  • Phone: 885-762-8088
  • Fax:
Mailing address:
  • Phone: 314-740-0786
  • Fax: 818-963-5270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: CHELSEY SORENSEN
Title or Position: VP RCM AND UR
Credential:
Phone: 314-740-0786