Provider Demographics
NPI:1376860403
Name:RESTORATION HEALTHCARE OF COMMERCE, LLC
Entity type:Organization
Organization Name:RESTORATION HEALTHCARE OF COMMERCE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
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:865-607-9923
Mailing Address - Street 1:70 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:COMMERCE
Mailing Address - State:GA
Mailing Address - Zip Code:30529-1078
Mailing Address - Country:US
Mailing Address - Phone:706-335-1000
Mailing Address - Fax:706-335-7701
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:706-335-7701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-29
Last Update Date:2010-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-078-0292314000000X, 313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000059331AMedicaid
GA000059331AMedicaid