Provider Demographics
NPI:1265420327
Name:GREENSBORO DIALYSIS FACILITY, L.L.C.
Entity type:Organization
Organization Name:GREENSBORO DIALYSIS FACILITY, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE ASSISTANT
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:S
Authorized Official - Last Name:SHIRLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-433-0683
Mailing Address - Street 1:PO BOX 390
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30642-0390
Mailing Address - Country:US
Mailing Address - Phone:706-433-0683
Mailing Address - Fax:706-369-1478
Practice Address - Street 1:1220 SILOAM RD
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:GA
Practice Address - Zip Code:30642-2810
Practice Address - Country:US
Practice Address - Phone:706-453-7222
Practice Address - Fax:706-453-0022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-12
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAESRD001127261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA112640Medicare ID - Type Unspecified