Provider Demographics
NPI:1740577949
Name:RESTORATION HEALTHCARE OF COMMERCE LLC
Entity Type:Organization
Organization Name:RESTORATION HEALTHCARE OF COMMERCE LLC
Other - Org Name:NORTHRIDGE MEDICAL EQUIPMENT SUPPLY OF COMMERCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:N
Authorized Official - Last Name:CLAPP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-335-1000
Mailing Address - Street 1:641 HOSPITAL RD STE 1
Mailing Address - Street 2:
Mailing Address - City:COMMERCE
Mailing Address - State:GA
Mailing Address - Zip Code:30529-1155
Mailing Address - Country:US
Mailing Address - Phone:706-335-1000
Mailing Address - Fax:706-335-4999
Practice Address - Street 1:70 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:COMMERCE
Practice Address - State:GA
Practice Address - Zip Code:30529-1078
Practice Address - Country:US
Practice Address - Phone:706-335-1000
Practice Address - Fax:706-335-4999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-08
Last Update Date:2011-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA078-665332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000000151AMedicaid
GA000000151AMedicaid