Healthcare Provider Details

I. General information

NPI: 1801139019
Provider Name (Legal Business Name): RESTORE INTERVENTIONAL SPINE & SPORTS MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2013
Last Update Date: 10/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9925 SW NIMBUS AVE SUITE 100
BEAVERTON OR
97008
US

IV. Provider business mailing address

9925 SW NIMBUS AVE. SUITE 100
BEAVERTON OR
97008
US

V. Phone/Fax

Practice location:
  • Phone: 503-535-8302
  • Fax: 503-416-8732
Mailing address:
  • Phone: 503-535-8302
  • Fax: 503-416-8732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberDO150752
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberMD28444
License Number StateOR

VIII. Authorized Official

Name: RAHUL NAVEN DESAI
Title or Position: OWNER / CEO
Credential: MD
Phone: 503-535-8302