Provider Demographics
NPI:1912079039
Name:RESTORATION HEALTH CARE OF COMMERCE, LLC
Entity Type:Organization
Organization Name:RESTORATION HEALTH CARE OF COMMERCE, LLC
Other - Org Name:NORTHRIDGE MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:WISE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-335-1101
Mailing Address - Street 1:70 MEDICAL CENTER DRIVE
Mailing Address - Street 2:
Mailing Address - City:COMMERCE
Mailing Address - State:GA
Mailing Address - Zip Code:30529
Mailing Address - Country:US
Mailing Address - Phone:706-335-1120
Mailing Address - Fax:706-335-6033
Practice Address - Street 1:70 MEDICAL CENTER DRIVE
Practice Address - Street 2:
Practice Address - City:COMMERCE
Practice Address - State:GA
Practice Address - Zip Code:30529
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:2006-11-14
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NR1301XHospitalsGeneral Acute Care HospitalRural
No273R00000XHospital UnitsPsychiatric Unit
No275N00000XHospital UnitsMedicare Defined Swing Bed Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA852155OtherBLUE CROSS CLINIC
GA00559248CMedicaid
GA00059331AMedicaid
GA191184OtherBLUE CROSS CRNA
GA00000151AMedicaid
GA00000151DMedicaid
GA00304059GMedicaid
GA00808244AMedicaid
GA00000151SMedicaid
GA000042OtherBLUE CROSS
GA191184OtherBLUE CROSS CRNA
GA110040Medicare Oscar/Certification
GA00304059GMedicaid
GA00059331AMedicaid
GA00000151DMedicaid
GA00808244AMedicaid
GA00808244AMedicaid
GA11U040Medicare Oscar/Certification