Provider Demographics
NPI:1538615695
Name:LIFE RESTORE MD
Entity type:Organization
Organization Name:LIFE RESTORE MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:N
Authorized Official - Last Name:CHAVARRIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-583-5807
Mailing Address - Street 1:3012 E HEBRON PKWY
Mailing Address - Street 2:SUITE 116
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75010-4464
Mailing Address - Country:US
Mailing Address - Phone:214-444-7567
Mailing Address - Fax:
Practice Address - Street 1:3012 E HEBRON PKWY
Practice Address - Street 2:SUITE 116
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75010-4464
Practice Address - Country:US
Practice Address - Phone:214-444-7567
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-29
Last Update Date:2016-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty