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General NPI Number Information
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NPI Number | 1750846465
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Entity Type | Organization
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Legal Business Name | 4 2 RESTORE DRUG & ALCOHOL RECOVERY CENTER
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Dates
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Enumeration Date | 02/06/2019
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Last Update Date | 02/06/2019
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Provider Practice Location Address
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Address Line | 302 PARK AVE
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City | BALTIMORE
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State | MD
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Zip | 21201-3618
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Country | US
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Telephone | 443-500-4887
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Fax |
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Provider Business Mailing Address
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Address Line | 302 PARK AVE
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City | BALTIMORE
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State | MD
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Zip | 21201-3618
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Country | US
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Telephone | 443-500-4887
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | DR. DEADRA MONIQUE MARTIN
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Credential | PHD
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Telephone | 443-500-4887
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number |
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License Number State |
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