Provider Demographics
NPI:1144973116
Name:RESTORE ADDICTION RECOVERY AND WELLNESS LLC
Entity type:Organization
Organization Name:RESTORE ADDICTION RECOVERY AND WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:L
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, SAP, MAC
Authorized Official - Phone:724-825-5527
Mailing Address - Street 1:613 BURROUGHS ST
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-3332
Mailing Address - Country:US
Mailing Address - Phone:724-825-5527
Mailing Address - Fax:
Practice Address - Street 1:613 BURROUGHS ST
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-3332
Practice Address - Country:US
Practice Address - Phone:724-825-5527
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-31
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV170OtherSTATE OF WV