Healthcare Provider Details

I. General information

NPI: 1588436265
Provider Name (Legal Business Name): RESTORE ARK HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2023
Last Update Date: 12/21/2024
Certification Date: 12/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 WATCHUNG AVE # 1006
PLAINFIELD NJ
07060-1251
US

IV. Provider business mailing address

108 WATCHUNG AVE # 1006
PLAINFIELD NJ
07060-1251
US

V. Phone/Fax

Practice location:
  • Phone: 201-354-7112
  • Fax: 973-833-1466
Mailing address:
  • Phone: 201-354-7112
  • Fax: 973-833-1466

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: OYEBOLA ASENUGA
Title or Position: APN
Credential: PMHNP
Phone: 201-354-7112