Provider Demographics
NPI:1740213123
Name:DIALYSIS CLINIC INC.
Entity Type:Organization
Organization Name:DIALYSIS CLINIC INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DONOVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHULTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-327-3061
Mailing Address - Street 1:3555 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37409-1028
Mailing Address - Country:US
Mailing Address - Phone:423-756-8808
Mailing Address - Fax:423-756-4397
Practice Address - Street 1:3555 BROAD ST
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37409-1028
Practice Address - Country:US
Practice Address - Phone:423-756-8808
Practice Address - Fax:423-756-4397
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000047261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0000452537AMedicaid
GA00482457AMedicaid
TN044-2555Medicaid
ILTN0112Medicaid
GA00482457AMedicaid