Healthcare Provider Details

I. General information

NPI: 1477994184
Provider Name (Legal Business Name): HEPHZIBAH DIALYSIS CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2013
Last Update Date: 01/13/2023
Certification Date: 01/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2516 TOBACCO RD
HEPHZIBAH GA
30815-7099
US

IV. Provider business mailing address

2516 TOBACCO RD
HEPHZIBAH GA
30815-7099
US

V. Phone/Fax

Practice location:
  • Phone: 706-790-9314
  • Fax: 706-790-9315
Mailing address:
  • Phone: 706-790-9314
  • Fax: 706-790-9315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: SARA ANNE BRADY
Title or Position: CHIEF NURSING OFFICER
Credential:
Phone: 208-371-7878