Healthcare Provider Details

I. General information

NPI: 1194757237
Provider Name (Legal Business Name): NRA-VALDOSTA, GEORGIA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 10/17/2023
Certification Date: 10/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 S PATTERSON ST
VALDOSTA GA
31601-6347
US

IV. Provider business mailing address

1115 S PATTERSON ST
VALDOSTA GA
31601-6347
US

V. Phone/Fax

Practice location:
  • Phone: 229-244-6045
  • Fax: 229-244-6291
Mailing address:
  • Phone: 229-244-6045
  • Fax: 229-244-6291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0700X
TaxonomyEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center
License NumberESRD00796
License Number StateGA

VIII. Authorized Official

Name: BARRY L. BLANTON
Title or Position: VICE PRESIDENT
Credential:
Phone: 781-699-9000