Provider Demographics
NPI:1427332428
Name:RESTORIX MEDICAL GROUP PLLC
Entity type:Organization
Organization Name:RESTORIX MEDICAL GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:FALLOU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-688-3734
Mailing Address - Street 1:PO BOX 190
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98009-0190
Mailing Address - Country:US
Mailing Address - Phone:425-688-3730
Mailing Address - Fax:425-453-6345
Practice Address - Street 1:1015 25TH ST
Practice Address - Street 2:
Practice Address - City:ANACORTES
Practice Address - State:WA
Practice Address - Zip Code:98221-2703
Practice Address - Country:US
Practice Address - Phone:360-899-4600
Practice Address - Fax:360-899-4601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-09
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8897944Medicare PIN