Healthcare Provider Details

I. General information

NPI: 1669306049
Provider Name (Legal Business Name): RESTORE HYDRATION & WELLNESS CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2026
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1838B W 95TH ST
CHICAGO IL
60643-1104
US

IV. Provider business mailing address

1838B W 95TH ST
CHICAGO IL
60643-1104
US

V. Phone/Fax

Practice location:
  • Phone: 779-374-1207
  • Fax:
Mailing address:
  • Phone: 779-374-1207
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LC1500X
TaxonomyCommunity Health Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MS. KEINESHA S COX
Title or Position: OWNER
Credential:
Phone: 779-374-1207