Provider Demographics
NPI:1962953810
Name:RESTORATION WELLNESS, LLC
Entity type:Organization
Organization Name:RESTORATION WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LYDIA
Authorized Official - Middle Name:M
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:ANP
Authorized Official - Phone:907-376-7300
Mailing Address - Street 1:PO BOX 876089
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99687-6089
Mailing Address - Country:US
Mailing Address - Phone:907-376-7300
Mailing Address - Fax:888-977-2041
Practice Address - Street 1:5805 E COLUMBUS WAY
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7831
Practice Address - Country:US
Practice Address - Phone:907-376-7300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-16
Last Update Date:2016-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1042971261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care