Provider Demographics
NPI:1114290368
Name:GREENVILLE DIALYSIS CLINIC LLC
Entity Type:Organization
Organization Name:GREENVILLE DIALYSIS CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF NURSING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SARA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:BRADY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-371-7878
Mailing Address - Street 1:220 HOWE ST
Mailing Address - Street 2:SUITE 220A
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-3524
Mailing Address - Country:US
Mailing Address - Phone:864-271-2002
Mailing Address - Fax:864-271-2003
Practice Address - Street 1:220 HOWE ST
Practice Address - Street 2:SUITE 220A
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29601-3524
Practice Address - Country:US
Practice Address - Phone:864-271-2002
Practice Address - Fax:864-271-2003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-20
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCRE0040Medicaid
SCRE0040Medicaid