Provider Demographics
NPI:1568954279
Name:RESTART CLINIC, PLLC
Entity Type:Organization
Organization Name:RESTART CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:L
Authorized Official - Last Name:HOLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:859-264-7722
Mailing Address - Street 1:2112 CAVE HILL LN
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40513-1055
Mailing Address - Country:US
Mailing Address - Phone:859-224-8835
Mailing Address - Fax:
Practice Address - Street 1:129 EDGEWOOD PLAZA DR
Practice Address - Street 2:
Practice Address - City:NICHOLASVILLE
Practice Address - State:KY
Practice Address - Zip Code:40356-1818
Practice Address - Country:US
Practice Address - Phone:859-264-7722
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-30
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty