=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043597503
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RESTORE WELLNESS CENTER, S.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/12/2011
-----------------------------------------------------
Last Update Date | 11/12/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 41 ACME RD SUITE 2
-----------------------------------------------------
City | BREWER
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04412-1543
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-989-9008
-----------------------------------------------------
Fax | 207-989-9007
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 41 ACME RD SUITE 2
-----------------------------------------------------
City | BREWER
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04412-1543
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-989-9008
-----------------------------------------------------
Fax | 207-989-9007
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | DIANE OUELLETTE
-----------------------------------------------------
Credential | NP
-----------------------------------------------------
Telephone | 207-989-9008
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | AP081148
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------