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General NPI Number Information
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NPI Number | 1497439509
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Entity Type | Organization
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Legal Business Name | RESTORE FIRST HEALTH RIVERDALE LLC
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Dates
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Enumeration Date | 06/12/2023
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Last Update Date | 10/29/2024
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Provider Practice Location Address
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Address Line | 34 UPPER RIVERDALE RD SE STE 101
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City | RIVERDALE
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State | GA
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Zip | 30274-2635
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Country | US
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Telephone | 470-292-3820
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Fax | 470-280-9511
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Provider Business Mailing Address
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Address Line | 10680 MEDLOCK BRIDGE RD STE 101
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City | JOHNS CREEK
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State | GA
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Zip | 30097-8420
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Country | US
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Telephone | 470-292-3820
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE VICE PRESIDENT, SGI
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Name | RANDALL LEE HAUPT
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Credential | MHA
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Telephone | 931-494-7057
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RR0500X
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Taxonomy Name | Rheumatology Physician
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License Number |
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License Number State |
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