Provider Demographics
NPI:1366734352
Name:AGAPE RESTORE RESTYLE AND CLEAN,INC
Entity type:Organization
Organization Name:AGAPE RESTORE RESTYLE AND CLEAN,INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCMONIGAL
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:612-849-8811
Mailing Address - Street 1:500 WYOMING ST E
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55107-2473
Mailing Address - Country:US
Mailing Address - Phone:612-849-8811
Mailing Address - Fax:651-493-0725
Practice Address - Street 1:500 WYOMING ST E
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55107-2473
Practice Address - Country:US
Practice Address - Phone:612-849-8811
Practice Address - Fax:651-493-0725
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-09
Last Update Date:2011-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174H00000X, 376J00000X
MN20630898171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Multi-Specialty
No174H00000XOther Service ProvidersHealth EducatorGroup - Multi-Specialty
No376J00000XNursing Service Related ProvidersHomemakerGroup - Multi-Specialty