Provider Demographics
NPI:1992362412
Name:THE RESTORE CLINIC
Entity Type:Organization
Organization Name:THE RESTORE CLINIC
Other - Org Name:THE RESTORE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:GROCE
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:615-419-0759
Mailing Address - Street 1:206 LAKE FARM RD
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:TN
Mailing Address - Zip Code:37167-3114
Mailing Address - Country:US
Mailing Address - Phone:615-419-0759
Mailing Address - Fax:
Practice Address - Street 1:268 VETERANS PKWY STE F
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37128-6432
Practice Address - Country:US
Practice Address - Phone:615-488-4172
Practice Address - Fax:615-454-9827
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-20
Last Update Date:2020-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty