=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710793609
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RESTORALIFE WELLNESS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/05/2024
-----------------------------------------------------
Last Update Date | 01/23/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 845 W MAPLE ST
-----------------------------------------------------
City | ONTARIO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91762-5935
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-992-6315
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 976
-----------------------------------------------------
City | RANCHO CUCAMONGA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91729-0976
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-992-6315
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MARCUS RAMEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 909-992-6315
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251X00000X
-----------------------------------------------------
Taxonomy Name | Supports Brokerage Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------