MEDICARE: ALPHA RESTORATION, LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251B00000X	Case Management Agency
2	305S00000X	Point of Service

General Provider Information

NPI Number	:	1770137010
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALPHA RESTORATION, LLC

Provider Business Mailing Address
First Line	:	PO BOX 15344
Second Line	:
City	:	COLORADO SPGS
State	:	CO
Zip	:	80935-5344
Country	:	US
Telephone Number	:	303-883-5767
Fax Number	:

Provider Business Practice Location Address
First Line	:	1320 MICHELLE CT APT S
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80916-1908
Country	:	US
Telephone Number	:	303-883-5767
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	BRENDAN MOOREHEAD
Credential	:	BA, MS
Telephone Number	:	303-883-5767

Provider Enumeration Date	:	07/25/2019
Last Update Date	:	11/25/2019

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