1316564909 NPI number — KIDNEY NUTRITION SPECIALIST LLC

Table of content: (NPI 1316564909)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316564909 NPI number — KIDNEY NUTRITION SPECIALIST LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KIDNEY NUTRITION SPECIALIST 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:
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:
1316564909
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/08/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
213 HIGHLAND HILLS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAYETTEVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30214-5429
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-568-0162
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1425 HIGHWAY 34 E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWNAN
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30265-1323
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
470-205-0119
Provider Business Practice Location Address Fax Number:
770-580-1880
Provider Enumeration Date:
06/29/2020

Additional Information

Authorized Official

Authorized Official Last Name:
HOOKS
Authorized Official First Name:
JADEDA
Authorized Official Middle Name:
DARWASHIA
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
770-568-0162

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 133VN1005X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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