NPIMap

Organization Active NPI

Restoration Clinic

  • Rural Health Clinic/Center
  • Decatur, TN
National Provider Identifier
1205248796
Registry record updated Apr 8, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
RESTORATION CLINIC
Practice address
17619 State Highway 58 N Ste C
Decatur, TN 37322-7882
Phone
(423) 506-3781
NPI assigned
Jun 2, 2014
Last updated
Apr 8, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 8, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
English Paige RobertsNPI 1326384991
Title
Owner
Phone
(423) 506-3781

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X TN Primary
Family Nurse Practitioner 363LF0000X NU
Primary Care Nurse Practitioner 363LP2300X NU

Addresses

Primary practice location

17619 State Highway 58 N Ste C
Decatur, TN 37322-7882

Mailing address

PO Box 1094
Decatur, TN 37322-1094
Phone (423) 506-3781

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in TN2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20140729000468 TN Part B Supplier - Clinic/Group Practice 1456577451 Receives reassigned benefits from 13 practitioners
2 other NPIs on this enrollment
Practice locations: Decatur, TN
O20180627003041 TN Part A Provider - Rural Health Clinic 1456577451 Practice locations: Decatur, TN

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1205248796. Details of each certification follow.

Rural health clinic certification: CCN 448997

Legal name
RESTORATION CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Sep 14, 2018
Last certification
Aug 7, 2018
Ownership / control type
1A
Organization structure
LLCProprietary
Enrollment address
17619 State Highway 58 N
Ste C
Decatur, TN 37322-7882

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 2

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 1

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
English Paige Roberts Individual 5% Or Greater Direct Ownership InterestPresident May 13, 2014 100%
Corporate OfficerPresident May 13, 2014 100%
Operational/Managerial ControlPresident May 13, 2014 100%

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Practitioners & affiliated clinicians

Practitioners 13

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 13

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1401667200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1712534400000",
    "number": "1205248796",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1094",
            "city": "DECATUR",
            "state": "TN",
            "postal_code": "373221094",
            "telephone_number": "423-506-3781",
            "fax_number": "423-454-0178"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "17619 STATE HIGHWAY 58 N STE C",
            "city": "DECATUR",
            "state": "TN",
            "postal_code": "373227882",
            "telephone_number": "423-506-3781"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "RESTORATION CLINIC",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-06-02",
        "last_updated": "2024-04-08",
        "certification_date": "2024-03-27",
        "status": "A",
        "authorized_official_last_name": "ROBERTS",
        "authorized_official_first_name": "ENGLISH",
        "authorized_official_middle_name": "PAIGE",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "423-506-3781"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "TN",
            "license": null,
            "primary": true
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "363LP2300X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Primary Care",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Decatur, TN

Sources for this page

Verify at the official NPI Registry.