Provider Demographics
NPI:1558541318
Name:NRA-VALDOSTA (NORTH), GEORGIA, LLC
Entity Type:Organization
Organization Name:NRA-VALDOSTA (NORTH), GEORGIA, LLC
Other - Org Name:KINGS WAY DIALYSIS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BLANTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-699-9000
Mailing Address - Street 1:4358 KINGS WAY
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-6921
Mailing Address - Country:US
Mailing Address - Phone:229-244-6923
Mailing Address - Fax:229-244-6958
Practice Address - Street 1:4358 KINGS WAY
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-6921
Practice Address - Country:US
Practice Address - Phone:229-244-6923
Practice Address - Fax:229-244-6958
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FRESENIUS MEDICAL CARE HOLDINGS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-09
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAESRD000778261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA112791Medicare Oscar/Certification