Provider Demographics
NPI:1982091294
Name:HARBIN CLINIC, LLC
Entity Type:Organization
Organization Name:HARBIN CLINIC, LLC
Other - Org Name:HARBIN CLINIC CALHOUN DIALYSIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:FRANKLIN
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-295-5331
Mailing Address - Street 1:1825 MARTHA BERRY BLVD NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-1625
Mailing Address - Country:US
Mailing Address - Phone:706-295-5331
Mailing Address - Fax:
Practice Address - Street 1:855 CURTIS PKWY SE
Practice Address - Street 2:
Practice Address - City:CALHOUN
Practice Address - State:GA
Practice Address - Zip Code:30701-3688
Practice Address - Country:US
Practice Address - Phone:706-238-8088
Practice Address - Fax:706-235-3104
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HARBIN CLINIC, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-04-24
Last Update Date:2015-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAESRD001288261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA112612Medicare PIN