Healthcare Provider Details

I. General information

NPI: 1417664616
Provider Name (Legal Business Name): GEORGIA KIDNEY CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2022
Last Update Date: 10/28/2022
Certification Date: 10/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3382 GRACE FARM LN
BUFORD GA
30519
US

IV. Provider business mailing address

2725 HAMILTON MILL RD STE 500
BUFORD GA
30519-6010
US

V. Phone/Fax

Practice location:
  • Phone: 404-731-6033
  • Fax:
Mailing address:
  • Phone: 404-731-6033
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QE0700X
TaxonomyEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RIYADH R AL-RUBAYE
Title or Position: OWNER
Credential: MD
Phone: 47-316-0334