Healthcare Provider Details

I. General information

NPI: 1861710998
Provider Name (Legal Business Name): GEORGIA QUALITY KIDNEY CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2010
Last Update Date: 06/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 CAMDEN HILL ROAD SUITE F
LAWRENCEVILLE GA
30046
US

IV. Provider business mailing address

170 CAMDEN HILL RD SUITE F
LAWRENCEVILLE GA
30046-7418
US

V. Phone/Fax

Practice location:
  • Phone: 770-339-4225
  • Fax: 770-339-4797
Mailing address:
  • Phone: 770-339-4225
  • Fax: 770-339-4797

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number046206
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number StateGA

VIII. Authorized Official

Name: DR. WILLIAM G PAXTON
Title or Position: MANAGING MEMBER
Credential: MD, PHD
Phone: 770-339-4225