Provider Demographics
NPI:1558769406
Name:MILLEN DIALYSIS CLINIC LLC
Entity Type:Organization
Organization Name:MILLEN DIALYSIS CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MRS
Authorized Official - First Name:SARA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-371-7878
Mailing Address - Street 1:242 N MASONIC ST
Mailing Address - Street 2:
Mailing Address - City:MILLEN
Mailing Address - State:GA
Mailing Address - Zip Code:30442-1611
Mailing Address - Country:US
Mailing Address - Phone:478-982-9533
Mailing Address - Fax:478-982-9535
Practice Address - Street 1:242 N MASONIC ST
Practice Address - Street 2:
Practice Address - City:MILLEN
Practice Address - State:GA
Practice Address - Zip Code:30442-1611
Practice Address - Country:US
Practice Address - Phone:478-982-9533
Practice Address - Fax:478-982-9535
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-09
Last Update Date:2024-02-05
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
GA000791304AMedicaid
GA000791304AMedicaid