Healthcare Provider Details

I. General information

NPI: 1245287358
Provider Name (Legal Business Name): NRA MONTICELLO GEORGIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 07/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1393 FUNDERBURG DR
MONTICELLO GA
31064-6818
US

IV. Provider business mailing address

1550 W. MCEWEN DRIVE SUITE 500
FRANKLIN TN
37067-1731
US

V. Phone/Fax

Practice location:
  • Phone: 706-468-1240
  • Fax: 706-468-5300
Mailing address:
  • Phone: 615-661-1100
  • Fax: 615-507-3300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0700X
TaxonomyEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center
License NumberESRD001221
License Number StateGA

VIII. Authorized Official

Name: MR. JON M. SUNDOCK
Title or Position: VICE PRESIDENT
Credential:
Phone: 615-507-3307