MEDICARE: JACKSON DIALYSIS CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QE0700X	End-Stage Renal Disease (ESRD) Treatment Clinic/Center		GA

General Provider Information

NPI Number	:	1033329198
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JACKSON DIALYSIS CENTER

Provider Business Mailing Address
First Line	:	PO BOX 888
Second Line	:
City	:	JACKSON
State	:	GA
Zip	:	30233-0019
Country	:	US
Telephone Number	:	770-504-9525
Fax Number	:

Provider Business Practice Location Address
First Line	:	794 MCDONOUGH RD
Second Line	:	SUITE 108
City	:	JACKSON
State	:	GA
Zip	:	30233-1572
Country	:	US
Telephone Number	:	770-504-9525
Fax Number	:

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. BABATUNDE FARIYIKE
Credential	:
Telephone Number	:	706-647-8065

Provider Enumeration Date	:	05/23/2007
Last Update Date	:	08/22/2020

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