Provider Demographics
NPI:1497439509
Name:RESTORE FIRST HEALTH RIVERDALE LLC
Entity Type:Organization
Organization Name:RESTORE FIRST HEALTH RIVERDALE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:HAUPT
Authorized Official - Suffix:
Authorized Official - Credentials:MHA
Authorized Official - Phone:931-494-7057
Mailing Address - Street 1:10680 MEDLOCK BRIDGE RD STE 101
Mailing Address - Street 2:
Mailing Address - City:JOHNS CREEK
Mailing Address - State:GA
Mailing Address - Zip Code:30097-8420
Mailing Address - Country:US
Mailing Address - Phone:470-292-3820
Mailing Address - Fax:
Practice Address - Street 1:34 UPPER RIVERDALE RD SE STE 101
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-2635
Practice Address - Country:US
Practice Address - Phone:470-292-3820
Practice Address - Fax:470-280-9511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-12
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Multi-Specialty