Provider Demographics
NPI:1891712766
Name:SOUTH ATLANTA KIDNEY CARE DIALYSIS
Entity Type:Organization
Organization Name:SOUTH ATLANTA KIDNEY CARE DIALYSIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN-MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:WAINDEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BELIZAIRE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:770-994-0171
Mailing Address - Street 1:195 UPPER RIVERDALE RD SUITE A
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274
Mailing Address - Country:US
Mailing Address - Phone:770-994-0171
Mailing Address - Fax:770-507-4190
Practice Address - Street 1:2221 PEACHTREE RD NE
Practice Address - Street 2:SUITE D 195
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1148
Practice Address - Country:US
Practice Address - Phone:770-994-0171
Practice Address - Fax:770-507-4190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2008-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA052252261QE0700X
GA112780261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA626468445AMedicaid
GA626468445AMedicaid