1245287358 NPI number — NRA MONTICELLO GEORGIA LLC

Table of content: (NPI 1245287358)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245287358 NPI number — NRA MONTICELLO GEORGIA LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NRA MONTICELLO GEORGIA LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MONTICELLO DIALYSIS CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245287358
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/22/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1550 W. MCEWEN DRIVE
Provider Second Line Business Mailing Address:
SUITE 500
Provider Business Mailing Address City Name:
FRANKLIN
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37067-1731
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-661-1100
Provider Business Mailing Address Fax Number:
615-507-3300

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1393 FUNDERBURG DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONTICELLO
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31064-6818
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-468-1240
Provider Business Practice Location Address Fax Number:
706-468-5300
Provider Enumeration Date:
05/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SUNDOCK
Authorized Official First Name:
JON
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
615-507-3307

Provider Taxonomy Codes

  • Taxonomy code: 261QE0700X , with the licence number:  ESRD001221 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 11D1049750 . This is a "CLIA CERTIFICATE OF WAIVE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 419934334A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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