Healthcare Provider Details

I. General information

NPI: 1558541318
Provider Name (Legal Business Name): NRA-VALDOSTA (NORTH), GEORGIA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2007
Last Update Date: 08/20/2021
Certification Date: 08/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4358 KINGS WAY
VALDOSTA GA
31602-6921
US

IV. Provider business mailing address

4358 KINGS WAY
VALDOSTA GA
31602-6921
US

V. Phone/Fax

Practice location:
  • Phone: 229-244-6923
  • Fax: 229-244-6958
Mailing address:
  • Phone: 229-244-6923
  • Fax: 229-244-6958

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0700X
TaxonomyEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center
License NumberESRD000778
License Number StateGA

VIII. Authorized Official

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