Provider Demographics
NPI:1265044788
Name:4 2 RESTORE LLC
Entity Type:Organization
Organization Name:4 2 RESTORE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DEADRA
Authorized Official - Middle Name:MONIQUE
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-701-9190
Mailing Address - Street 1:3527 N ROLLING RD STE 4
Mailing Address - Street 2:
Mailing Address - City:WINDSOR MILL
Mailing Address - State:MD
Mailing Address - Zip Code:21244-2256
Mailing Address - Country:US
Mailing Address - Phone:410-701-9190
Mailing Address - Fax:410-701-7483
Practice Address - Street 1:3527 N ROLLING RD STE 4
Practice Address - Street 2:
Practice Address - City:WINDSOR MILL
Practice Address - State:MD
Practice Address - Zip Code:21244-2256
Practice Address - Country:US
Practice Address - Phone:410-701-9190
Practice Address - Fax:410-701-7483
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-17
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder