1912079039 NPI number — RESTORATION HEALTH CARE OF COMMERCE, LLC

Table of content: (NPI 1912079039)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912079039 NPI number — RESTORATION HEALTH CARE OF COMMERCE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RESTORATION HEALTH CARE OF COMMERCE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1912079039
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/12/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
70 MEDICAL CENTER DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COMMERCE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30529
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-335-1120
Provider Business Mailing Address Fax Number:
706-335-6033

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
70 MEDICAL CENTER DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COMMERCE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30529
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-335-1000
Provider Business Practice Location Address Fax Number:
706-335-7701
Provider Enumeration Date:
11/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WISE
Authorized Official First Name:
JERRY
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
706-335-1101

Provider Taxonomy Codes

  • Taxonomy code: 273R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 275N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 282NR1301X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 852155 . This is a "BLUE CROSS CLINIC" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 00559248C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00059331A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 191184 . This is a "BLUE CROSS CRNA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 00000151A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00000151D , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00304059G , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00808244A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00000151S , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000042 . This is a "BLUE CROSS" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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