1730522343 NPI number — INNOVATIVE DIALYSIS CENTERS OF LA GRANGE, LLC

Table of content: (NPI 1730522343)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730522343 NPI number — INNOVATIVE DIALYSIS CENTERS OF LA GRANGE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INNOVATIVE DIALYSIS CENTERS OF LA GRANGE, 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:
6
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:
1730522343
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/23/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1300 LAFAYETTE PKWY STE D
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAGRANGE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30241-2610
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:
781-419-0182

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1300 LAFAYETTE PKWY
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
LAGRANGE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30241-2612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-884-3765
Provider Business Practice Location Address Fax Number:
706-884-5304
Provider Enumeration Date:
04/12/2013

Additional Information

Authorized Official

Authorized Official Last Name:
BLANTON
Authorized Official First Name:
BARRY
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
VP
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: 003146669A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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