Healthcare Provider Details

I. General information

NPI: 1447640917
Provider Name (Legal Business Name): FIDELITY HOME DIALYSIS CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2015
Last Update Date: 05/31/2022
Certification Date: 05/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1230 JOHNSON FERRY PL STE H30
MARIETTA GA
30068-2058
US

IV. Provider business mailing address

1230 JOHNSON FERRY PL STE H30
MARIETTA GA
30068-2058
US

V. Phone/Fax

Practice location:
  • Phone: 678-742-8563
  • Fax: 678-742-8178
Mailing address:
  • Phone: 678-742-8563
  • Fax: 678-742-8178

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: STEVE FICKLIN
Title or Position: ADMINISTRATOR
Credential:
Phone: 501-217-3888