Provider Demographics
NPI:1114974516
Name:NRA-ORANGEBURG, SOUTH CAROLINA, LLC
Entity Type:Organization
Organization Name:NRA-ORANGEBURG, SOUTH CAROLINA, LLC
Other - Org Name:ORANGEBURG DIALYSIS CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BLANTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-699-9000
Mailing Address - Street 1:1184 ORANGEBURG MALL CIR
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29115-3439
Mailing Address - Country:US
Mailing Address - Phone:803-531-7501
Mailing Address - Fax:803-531-7553
Practice Address - Street 1:1184 ORANGEBURG MALL CIR
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29115-3439
Practice Address - Country:US
Practice Address - Phone:803-531-7501
Practice Address - Fax:803-531-7553
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FRESENIUS MEDICAL CARE HOLDINGS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-30
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCERD-131261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC42D1011036OtherCLIA CERTIFICATE OF WAIVE
SCERD131Medicaid
SC42D1011036OtherCLIA CERTIFICATE OF WAIVE