Provider Demographics
NPI:1699140152
Name:RESTORE HEALTH PLLC
Entity type:Organization
Organization Name:RESTORE HEALTH PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHINITA
Authorized Official - Middle Name:REED
Authorized Official - Last Name:DUDLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-957-7343
Mailing Address - Street 1:1551 E COUNTY LINE RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-1801
Mailing Address - Country:US
Mailing Address - Phone:601-957-7343
Mailing Address - Fax:601-957-7344
Practice Address - Street 1:1551 E COUNTY LINE RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-1801
Practice Address - Country:US
Practice Address - Phone:601-957-7343
Practice Address - Fax:601-957-7344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-09
Last Update Date:2016-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS18239261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care