Provider Demographics
NPI:1477994184
Name:HEPHZIBAH DIALYSIS CLINIC LLC
Entity Type:Organization
Organization Name:HEPHZIBAH DIALYSIS CLINIC 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 1:2516 TOBACCO RD
Mailing Address - Street 2:
Mailing Address - City:HEPHZIBAH
Mailing Address - State:GA
Mailing Address - Zip Code:30815-7099
Mailing Address - Country:US
Mailing Address - Phone:706-790-9314
Mailing Address - Fax:706-790-9315
Practice Address - Street 1:2516 TOBACCO RD
Practice Address - Street 2:
Practice Address - City:HEPHZIBAH
Practice Address - State:GA
Practice Address - Zip Code:30815-7099
Practice Address - Country:US
Practice Address - Phone:706-790-9314
Practice Address - Fax:706-790-9315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-10
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
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003143995AMedicaid
GA003143995AMedicaid