1477500890 NPI number — NRA-NORTH AUGUSTA, SOUTH CAROLINA, LLC

Table of content: (NPI 1477500890)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477500890 NPI number — NRA-NORTH AUGUSTA, SOUTH CAROLINA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NRA-NORTH AUGUSTA, SOUTH CAROLINA, 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:
FRESENIUS MEDICAL CARE ATOMIC ROAD
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:
1477500890
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/26/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10263 ATOMIC RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH AUGUSTA
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29841-4484
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-279-3722
Provider Business Mailing Address Fax Number:
803-279-3461

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10263 ATOMIC RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH AUGUSTA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29841-4484
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-279-3722
Provider Business Practice Location Address Fax Number:
803-279-3461
Provider Enumeration Date:
05/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FAWCETT
Authorized Official First Name:
MARK
Authorized Official Middle Name:
R.
Authorized Official Title or Position:
SVP & TREASURER
Authorized Official Telephone Number:
781-699-9000

Provider Taxonomy Codes

  • Taxonomy code: 261QE0700X , with the licence number:  ERD-173 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 42D1057702 . This is a "CLIA CERTIFICATE OF WAIVE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: ERD173 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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