1003928821 NPI number — CLAYTON COUNTY DIALYSIS, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003928821 NPI number — CLAYTON COUNTY DIALYSIS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLAYTON COUNTY DIALYSIS, 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 CLAYTON COUNTY
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:
1003928821
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/16/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
181 UPPER RIVERDALE RD SW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIVERDALE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30274-4919
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-996-9660
Provider Business Mailing Address Fax Number:
770-994-0016

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
181 UPPER RIVERDALE RD SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIVERDALE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30274-4919
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-996-9660
Provider Business Practice Location Address Fax Number:
770-994-0016
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BLANTON
Authorized Official First Name:
BARRY
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
781-699-9000

Provider Taxonomy Codes

  • Taxonomy code: 261QE0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000785056A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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