MEDICARE: RESTORE FIRST HEALTH MARIETTA LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1487378071
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RESTORE FIRST HEALTH MARIETTA LLC

Provider Business Mailing Address
First Line	:	2550 WINDY HILL RD SE STE 115
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30067-8607
Country	:	US
Telephone Number	:	678-580-2684
Fax Number	:

Provider Business Practice Location Address
First Line	:	2550 WINDY HILL RD SE STE 115
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30067-8607
Country	:	US
Telephone Number	:	678-580-2684
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE VICE PRESIDENT, SGI
Name	:	RANDALL LEE HAUPT
Credential	:
Telephone Number	:	470-292-3820

Provider Enumeration Date	:	09/28/2022
Last Update Date	:	10/29/2024

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