Healthcare Provider Details

I. General information

NPI: 1316855794
Provider Name (Legal Business Name): RESTORATION HEALTH MEDICAL GROUP PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2026
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

394 W MAIN ST STE 105
LEHI UT
84043
US

IV. Provider business mailing address

299 S. MAIN ST STE 1300 #93543
SALT LAKE CITY UT
84111
US

V. Phone/Fax

Practice location:
  • Phone: 385-606-0405
  • Fax: 385-437-1562
Mailing address:
  • Phone: 385-606-0405
  • Fax: 385-437-1562

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: JACOB PETROSKY
Title or Position: OWNER
Credential: MD
Phone: 385-606-0405