Healthcare Provider Details

I. General information

NPI: 1588981187
Provider Name (Legal Business Name): KIDNEY CARE CENTER OF GEORGIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2010
Last Update Date: 11/29/2023
Certification Date: 11/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

663 LANIER PARK DR
GAINESVILLE GA
30501-2059
US

IV. Provider business mailing address

663 LANIER PARK DR
GAINESVILLE GA
30501-2059
US

V. Phone/Fax

Practice location:
  • Phone: 678-450-0202
  • Fax: 678-450-0080
Mailing address:
  • Phone: 678-450-0202
  • Fax: 678-450-0080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number43717
License Number StateGA

VIII. Authorized Official

Name: DR. KHALED NASS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 678-450-0202