=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821536194
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IRESTORE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2017
-----------------------------------------------------
Last Update Date | 02/07/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 23945 CALABASAS RD
-----------------------------------------------------
City | CALABASAS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91302-1552
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 747-222-6505
-----------------------------------------------------
Fax | 800-662-1773
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 391
-----------------------------------------------------
City | AGOURA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91376-0391
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 747-222-6505
-----------------------------------------------------
Fax | 800-662-1773
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FOUNDER
-----------------------------------------------------
Name | RONALD CRAIG LEFKOWITZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 747-222-6505
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP3300X
-----------------------------------------------------
Taxonomy Name | Pain Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------