Provider Demographics
NPI:1417016551
Name:SOUTH FULTON DIALYSIS CENTER LLC
Entity Type:Organization
Organization Name:SOUTH FULTON DIALYSIS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BOB
Authorized Official - Middle Name:
Authorized Official - Last Name:AGBOGU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-669-9669
Mailing Address - Street 1:1151 CLEVELAND AVENUE
Mailing Address - Street 2:SUITE A/B
Mailing Address - City:EAST POINT
Mailing Address - State:GA
Mailing Address - Zip Code:30344-3618
Mailing Address - Country:US
Mailing Address - Phone:404-669-9669
Mailing Address - Fax:404-669-6998
Practice Address - Street 1:3268 GREENBRIAR PKWY SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331-2604
Practice Address - Country:US
Practice Address - Phone:404-997-6700
Practice Address - Fax:404-997-6710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2017-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAESRD001133261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000823853BMedicaid
GA000823853AMedicaid
GA000823853AMedicaid