MEDICARE: RESTORE HEALTHCARE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number State
1	235Z00000X	Speech-Language Pathologist
2	225X00000X	Occupational Therapist
3	225100000X	Physical Therapist
4	101YM0800X	Mental Health Counselor
5	133VN1005X	Renal Nutrition Registered Dietitian	NC
6	163WC0400X	Case Management Registered Nurse	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	REHABILITATIVE	OTHER	NC	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1639513708
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RESTORE HEALTHCARE

Provider Business Mailing Address
First Line	:	4258 HIGHWAY 49 S
Second Line	:	UNIT 554
City	:	HARRISBURG
State	:	NC
Zip	:	28075-0345
Country	:	US
Telephone Number	:	704-559-9408
Fax Number	:	704-731-0975

Provider Business Practice Location Address
First Line	:	4350 MAIN ST
Second Line	:	SUITE 211
City	:	HARRISBURG
State	:	NC
Zip	:	28075-7433
Country	:	US
Telephone Number	:	704-559-9408
Fax Number	:	704-731-0975

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	CHRIS JARRETT
Credential	:
Telephone Number	:	704-559-9408

Provider Enumeration Date	:	04/19/2013
Last Update Date	:	06/29/2015

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Directions to “RESTORE HEALTHCARE ” Practice Location

Language	Start Address	Practice Location

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