Provider Demographics
NPI:1548429822
Name:KIDNEY DIALYSIS CENTER, LLC
Entity Type:Organization
Organization Name:KIDNEY DIALYSIS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORGANIZER
Authorized Official - Prefix:
Authorized Official - First Name:AZMI
Authorized Official - Middle Name:
Authorized Official - Last Name:KABBANI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:478-745-5455
Mailing Address - Street 1:640 MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-3206
Mailing Address - Country:US
Mailing Address - Phone:478-742-5850
Mailing Address - Fax:478-742-5860
Practice Address - Street 1:640 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-3206
Practice Address - Country:US
Practice Address - Phone:478-742-5850
Practice Address - Fax:478-742-5860
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-03
Last Update Date:2008-10-15
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