Healthcare Provider Details

I. General information

NPI: 1366436313
Provider Name (Legal Business Name): RESTORATIVE WOMEN'S WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2005
Last Update Date: 04/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 N STOKESBERRY PL UNIT A
MERIDIAN ID
83646-1510
US

IV. Provider business mailing address

2525 N STOKESBERRY PL UNIT A
MERIDIAN ID
83646-1510
US

V. Phone/Fax

Practice location:
  • Phone: 208-378-1517
  • Fax: 208-939-8597
Mailing address:
  • Phone: 208-378-1517
  • Fax: 208-939-8597

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberAT-255
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT-255
License Number StateID

VIII. Authorized Official

Name: CHARITY KRISTIN BERRIER
Title or Position: OWNER
Credential: ATC, NTP, LMT
Phone: 208-866-6549