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NPI Code Detail

MEDICARE: RESTORATION WELLNESS, LLC

MEDICARE: RESTORATION WELLNESS, 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
1261QP2300XPrimary Care Clinic/Center1042971AK

General Provider Information

NPI Number : 1962953810
Entity Type Code : Organization
Provider Name (Legal Business Name) : RESTORATION WELLNESS, LLC
Provider Business Mailing Address
First Line : PO BOX 876089
Second Line :
City : WASILLA
State : AK
Zip : 99687-6089
Country : US
Telephone Number : 907-376-7300
Fax Number : 888-977-2041
Provider Business Practice Location Address
First Line : 5805 E COLUMBUS WAY
Second Line :
City : WASILLA
State : AK
Zip : 99654-7831
Country : US
Telephone Number : 907-376-7300
Fax Number :
Authorized Official
Title or Position : OWNER
Name : LYDIA M PETERSEN
Credential : ANP
Telephone Number : 907-376-7300
Provider Enumeration Date : 10/16/2016
Last Update Date : 12/30/2016

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Directions to “RESTORATION WELLNESS, LLC ” Practice Location

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