Provider Demographics
NPI:1033329198
Name:JACKSON DIALYSIS CENTER
Entity Type:Organization
Organization Name:JACKSON DIALYSIS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BABATUNDE
Authorized Official - Middle Name:
Authorized Official - Last Name:FARIYIKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-647-8065
Mailing Address - Street 1:PO BOX 888
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:GA
Mailing Address - Zip Code:30233-0019
Mailing Address - Country:US
Mailing Address - Phone:770-504-9525
Mailing Address - Fax:
Practice Address - Street 1:794 MCDONOUGH RD
Practice Address - Street 2:SUITE 108
Practice Address - City:JACKSON
Practice Address - State:GA
Practice Address - Zip Code:30233-1572
Practice Address - Country:US
Practice Address - Phone:770-504-9525
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
1127401Medicare ID - Type Unspecified