Provider Demographics
NPI:1144721192
Name:RESTORE HOUSE
Entity type:Organization
Organization Name:RESTORE HOUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREATMENT DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:E
Authorized Official - Last Name:GREER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-760-4209
Mailing Address - Street 1:PO BOX 1191
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56619-1191
Mailing Address - Country:US
Mailing Address - Phone:218-444-9420
Mailing Address - Fax:218-444-9212
Practice Address - Street 1:3007 BIRCHMONT DR NE
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-4324
Practice Address - Country:US
Practice Address - Phone:218-444-9420
Practice Address - Fax:218-444-9212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-26
Last Update Date:2018-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1089959.324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility