Healthcare Provider Details

I. General information

NPI: 1164455549
Provider Name (Legal Business Name): DIALYSIS CLINIC INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 10/04/2023
Certification Date: 10/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

614 PATTERSON RD
LA FAYETTE GA
30728-3326
US

IV. Provider business mailing address

614 PATTERSON RD
LA FAYETTE GA
30728-3326
US

V. Phone/Fax

Practice location:
  • Phone: 762-638-6553
  • Fax: 706-638-6605
Mailing address:
  • Phone: 706-638-6553
  • Fax: 706-638-6605

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0700X
TaxonomyEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center
License NumberESRD001103
License Number StateGA

VIII. Authorized Official

Name: MR. DONOVAN SCHULTZ
Title or Position: PRESIDENT
Credential:
Phone: 615-327-3061