MEDICARE: DIALYSIS ACCESS CENTER OF ATLANTA

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	174400000X	Specialist

General Provider Information

NPI Number	:	1770646747
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIALYSIS ACCESS CENTER OF ATLANTA

Provider Business Mailing Address
First Line	:	1639 PIERCE DR
Second Line	:	WMB 338
City	:	ATLANTA
State	:	GA
Zip	:	30322-0001
Country	:	US
Telephone Number	:	847-388-2032
Fax Number	:	847-388-2025

Provider Business Practice Location Address
First Line	:	552 PONCE DE LEON AVE NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30308-1806
Country	:	US
Telephone Number	:	404-872-3655
Fax Number	:	404-875-6328

Authorized Official
Title or Position	:	MANAGER
Name	:	MR. JAY COPELAND
Credential	:
Telephone Number	:	404-872-3655

Provider Enumeration Date	:	12/19/2006
Last Update Date	:	08/22/2020

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