Provider Demographics
NPI:1487378071
Name:RESTORE FIRST HEALTH MARIETTA LLC
Entity type:Organization
Organization Name:RESTORE FIRST HEALTH MARIETTA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT, SGI
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:HAUPT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:470-292-3820
Mailing Address - Street 1:2550 WINDY HILL RD SE STE 115
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-8607
Mailing Address - Country:US
Mailing Address - Phone:678-580-2684
Mailing Address - Fax:
Practice Address - Street 1:2550 WINDY HILL RD SE STE 115
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-8607
Practice Address - Country:US
Practice Address - Phone:678-580-2684
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-28
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty