Basic Information
| Provider Information | |||||||||
| NPI: | 1487370573 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RESTORE MEDICAL SPA, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12127B N STATE HWY 14 STE 5 | ||||||||
| Address2: | |||||||||
| City: | CEDAR CREST | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870089557 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052815180 | ||||||||
| FaxNumber: | 5052815320 | ||||||||
| Practice Location | |||||||||
| Address1: | 3500 CONSTITUTION AVE NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871061215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058141995 | ||||||||
| FaxNumber: | 5054335127 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2022 | ||||||||
| LastUpdateDate: | 10/19/2022 | ||||||||
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| AuthorizedOfficialLastName: | GALLEGOS | ||||||||
| AuthorizedOfficialFirstName: | VICTORIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5052815180 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2500X | Y | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty |
No ID Information.