Provider Demographics
NPI:1811395775
Name:SANDERSVILLE DIALYSIS CLINIC LLC
Entity Type:Organization
Organization Name:SANDERSVILLE DIALYSIS CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF NURSING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SARA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:BRADY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-371-7878
Mailing Address - Street 1:614 S HARRIS ST
Mailing Address - Street 2:
Mailing Address - City:SANDERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31082-2821
Mailing Address - Country:US
Mailing Address - Phone:478-552-6818
Mailing Address - Fax:478-552-0858
Practice Address - Street 1:614 S HARRIS ST
Practice Address - Street 2:
Practice Address - City:SANDERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:31082-2821
Practice Address - Country:US
Practice Address - Phone:478-552-6818
Practice Address - Fax:478-552-0858
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-09
Last Update Date:2023-01-13
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
GA000407591AMedicaid
TN112534Medicare Oscar/Certification