=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669306049
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RESTORE HYDRATION & WELLNESS CLINIC INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/10/2026
-----------------------------------------------------
Last Update Date | 06/10/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1838B W 95TH ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60643-1104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 779-374-1207
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1838B W 95TH ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60643-1104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 779-374-1207
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. KEINESHA S COX
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 779-374-1207
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LC1500X
-----------------------------------------------------
Taxonomy Name | Community Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LW0102X
-----------------------------------------------------
Taxonomy Name | Women's Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------