Healthcare Provider Details

I. General information

NPI: 1154806594
Provider Name (Legal Business Name): RENAL ASSOCIATES OF LAGRANGE AT EMORY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2018
Last Update Date: 10/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 LAFAYETTE PKWY STE D
LAGRANGE GA
30241-2610
US

IV. Provider business mailing address

6228 BRADLEY PARK DR STE A
COLUMBUS GA
31904-3605
US

V. Phone/Fax

Practice location:
  • Phone: 706-882-2800
  • Fax: 706-324-3419
Mailing address:
  • Phone: 706-322-1486
  • Fax: 706-324-3419

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: BEVERLY REYNOLDS
Title or Position: OFFICE MANAGER
Credential:
Phone: 706-322-1486