Provider Demographics
NPI:1821695164
Name:NORTH DAVIDSON DIALYSIS CENTER OF WAKE FOREST UNIVERSITY
Entity Type:Organization
Organization Name:NORTH DAVIDSON DIALYSIS CENTER OF WAKE FOREST UNIVERSITY
Other - Org Name:NORTH DAVIDSON DIALYSIS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF DEVELOPMENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDONALD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-387-3527
Mailing Address - Street 1:PO BOX 7710
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31793-7710
Mailing Address - Country:US
Mailing Address - Phone:229-387-3527
Mailing Address - Fax:229-386-2149
Practice Address - Street 1:295 MILLERS CREEK DRIVE
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27127
Practice Address - Country:US
Practice Address - Phone:336-793-0195
Practice Address - Fax:336-793-0415
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-08
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment