=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710438775
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RESTORATION HEALTH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/14/2016
-----------------------------------------------------
Last Update Date | 10/14/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17751 E WARREN AVE
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48224-1329
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-744-2164
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17751 E WARREN AVE
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48224-1329
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-744-2164
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DEQUINDRA QUINN
-----------------------------------------------------
Credential | RN NP-C
-----------------------------------------------------
Telephone | 313-744-2164
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 4704205118
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------