Provider Demographics
NPI:1235317454
Name:SOUTH HENRY DIALYSIS LLC
Entity Type:Organization
Organization Name:SOUTH HENRY DIALYSIS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:SHEILA
Authorized Official - Middle Name:
Authorized Official - Last Name:DIXON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-565-6228
Mailing Address - Street 1:3580 CAMERON PKWY
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-7816
Mailing Address - Country:US
Mailing Address - Phone:678-565-6228
Mailing Address - Fax:770-996-6279
Practice Address - Street 1:1095 HENRY PARKWAY CONNECTOR
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-6669
Practice Address - Country:US
Practice Address - Phone:678-565-6228
Practice Address - Fax:770-996-6279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-11
Last Update Date:2014-12-09
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
112799Medicare PIN