1033329198 NPI number — JACKSON DIALYSIS CENTER

Table of content: JOANNE C. STAVOLA MSW,LCSW (NPI 1316084254)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033329198 NPI number — JACKSON DIALYSIS CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JACKSON DIALYSIS CENTER
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:
Provider Other Organization Name Type Code:
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:
1033329198
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 888
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30233-0019
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-504-9525
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
794 MCDONOUGH RD
Provider Second Line Business Practice Location Address:
SUITE 108
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30233-1572
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-504-9525
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/23/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
FARIYIKE
Authorized Official First Name:
BABATUNDE
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
706-647-8065

Provider Taxonomy Codes

  • Taxonomy code: 261QE0700X , 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)