Provider Demographics
NPI:1043243421
Name:DIALYSIS CLINIC INC.
Entity Type:Organization
Organization Name:DIALYSIS CLINIC INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DONOVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHULTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-327-3061
Mailing Address - Street 1:155 BRANDYWINE BLVD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-7628
Mailing Address - Country:US
Mailing Address - Phone:770-716-6940
Mailing Address - Fax:770-716-6944
Practice Address - Street 1:155 BRANDYWINE BLVD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-7628
Practice Address - Country:US
Practice Address - Phone:770-716-6940
Practice Address - Fax:770-716-6944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAESRD001036261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000774287BMedicaid
GA00774287AMedicaid
WI00774287AMedicaid
GA00774287AMedicaid