Provider Demographics
NPI:1396452611
Name:RESTORE VASCULAR PLLC
Entity type:Organization
Organization Name:RESTORE VASCULAR PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:IAN
Authorized Official - Last Name:WELLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-874-6808
Mailing Address - Street 1:18510 E SAN TAN BLVD STE 115
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85142-2206
Mailing Address - Country:US
Mailing Address - Phone:480-442-3990
Mailing Address - Fax:
Practice Address - Street 1:18510 E SAN TAN BLVD STE 115
Practice Address - Street 2:
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85142-2206
Practice Address - Country:US
Practice Address - Phone:480-442-3990
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-07
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes202K00000XAllopathic & Osteopathic PhysiciansPhlebologyGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty