Provider Demographics
NPI:1073816112
Name:RESTORE PHYSICAL THERAPY AND WELLNESS LLC
Entity type:Organization
Organization Name:RESTORE PHYSICAL THERAPY AND WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:WARD
Authorized Official - Last Name:HENNE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:678-491-4729
Mailing Address - Street 1:415 BELLFLOWER CT
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-3369
Mailing Address - Country:US
Mailing Address - Phone:678-491-4729
Mailing Address - Fax:
Practice Address - Street 1:415 BELLFLOWER CT
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-3369
Practice Address - Country:US
Practice Address - Phone:678-491-4729
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-12
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT007124261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy