Provider Demographics
NPI:1598711871
Name:NRA-MILLEDGEVILLE GEORGIA LLC
Entity Type:Organization
Organization Name:NRA-MILLEDGEVILLE GEORGIA LLC
Other - Org Name:OCONEE DIALYSIS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JON
Authorized Official - Middle Name:M
Authorized Official - Last Name:SUNDOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-507-3307
Mailing Address - Street 1:1550 W. MCEWEN DRIVE
Mailing Address - Street 2:SUITE 500
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37067-1731
Mailing Address - Country:US
Mailing Address - Phone:615-661-1100
Mailing Address - Fax:615-507-3300
Practice Address - Street 1:421 N JEFFERSON ST NE
Practice Address - Street 2:
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-2920
Practice Address - Country:US
Practice Address - Phone:478-451-0064
Practice Address - Fax:478-453-8043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2015-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAESRD001231261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA11D1049749OtherCLIA CERTIFICATE OF WAIVE
GA230307270AMedicaid
GA230307270AMedicaid