Healthcare Provider Details

I. General information

NPI: 1184109803
Provider Name (Legal Business Name): RESTORATION HEALTH CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2018
Last Update Date: 02/16/2021
Certification Date: 02/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1541 N LINDBERG CIR
WICHITA KS
67206-6400
US

IV. Provider business mailing address

12300 E FOUR OAKS ST
WICHITA KS
67226-8366
US

V. Phone/Fax

Practice location:
  • Phone: 316-258-5882
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: JESSICA MANZANO
Title or Position: DIRECTOR OF REVENUE CYCLE
Credential:
Phone: 316-312-7780