Provider Demographics
NPI:1235649765
Name:FORT VALLEY DIALYSIS CENTER LLC
Entity Type:Organization
Organization Name:FORT VALLEY DIALYSIS CENTER 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 1:135 AVERA DR
Mailing Address - Street 2:
Mailing Address - City:FORT VALLEY
Mailing Address - State:GA
Mailing Address - Zip Code:31030-5007
Mailing Address - Country:US
Mailing Address - Phone:478-827-0776
Mailing Address - Fax:478-827-0699
Practice Address - Street 1:135 AVERA DR
Practice Address - Street 2:
Practice Address - City:FORT VALLEY
Practice Address - State:GA
Practice Address - Zip Code:31030-5007
Practice Address - Country:US
Practice Address - Phone:478-827-0776
Practice Address - Fax:478-827-0699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-11
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