Provider Demographics
NPI:1699005223
Name:MABLETON MEDICAL ENTERPRISES CORP
Entity Type:Organization
Organization Name:MABLETON MEDICAL ENTERPRISES CORP
Other - Org Name:MABLETON DIALYSIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:OLUFUNMILAYO
Authorized Official - Middle Name:N/A
Authorized Official - Last Name:ADEJOKUN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-728-2624
Mailing Address - Street 1:5080 JOHNS CREEK CT
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30022-5186
Mailing Address - Country:US
Mailing Address - Phone:850-728-2624
Mailing Address - Fax:
Practice Address - Street 1:1380 VETERANS MEMORIAL HWY SW
Practice Address - Street 2:
Practice Address - City:MABLETON
Practice Address - State:GA
Practice Address - Zip Code:30126-3112
Practice Address - Country:US
Practice Address - Phone:770-485-1773
Practice Address - Fax:770-627-3202
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MABLETON MEDICAL ENTERPRISES CORP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-01-04
Last Update Date:2015-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPENDING261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003104187AMedicaid
GA112834Medicare Oscar/Certification