Provider Demographics
NPI:1013393321
Name:CARTERSVILLE DIALYSIS SPA LLC
Entity Type:Organization
Organization Name:CARTERSVILLE DIALYSIS SPA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ADEBUSOLA
Authorized Official - Middle Name:
Authorized Official - Last Name:KEELS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-218-7290
Mailing Address - Street 1:40 SLOPES DR
Mailing Address - Street 2:
Mailing Address - City:CARTERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30120-7965
Mailing Address - Country:US
Mailing Address - Phone:678-218-7290
Mailing Address - Fax:
Practice Address - Street 1:40 SLOPES DR
Practice Address - Street 2:
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30120-7965
Practice Address - Country:US
Practice Address - Phone:678-218-7290
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-10
Last Update Date:2015-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment