Provider Demographics
NPI:1245227560
Name:TRINITY DIALYSIS CLINIC INC
Entity Type:Organization
Organization Name:TRINITY DIALYSIS CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:AKINTADE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-763-0405
Mailing Address - Street 1:1354 CLEVELAND AVE
Mailing Address - Street 2:
Mailing Address - City:EAST POINT
Mailing Address - State:GA
Mailing Address - Zip Code:30344-3431
Mailing Address - Country:US
Mailing Address - Phone:404-763-0405
Mailing Address - Fax:404-763-4223
Practice Address - Street 1:1354 CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:EAST POINT
Practice Address - State:GA
Practice Address - Zip Code:30344-3431
Practice Address - Country:US
Practice Address - Phone:404-763-0405
Practice Address - Fax:404-763-4223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-03
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000933831AMedicaid
GA112702Medicare ID - Type UnspecifiedPROVIDER NUMBER