Healthcare Provider Details

I. General information

NPI: 1477500890
Provider Name (Legal Business Name): NRA-NORTH AUGUSTA, SOUTH CAROLINA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2006
Last Update Date: 01/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10263 ATOMIC RD
NORTH AUGUSTA SC
29841-4484
US

IV. Provider business mailing address

10263 ATOMIC RD
NORTH AUGUSTA SC
29841-4484
US

V. Phone/Fax

Practice location:
  • Phone: 803-279-3722
  • Fax: 803-279-3461
Mailing address:
  • Phone: 803-279-3722
  • Fax: 803-279-3461

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0700X
TaxonomyEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center
License NumberERD-173
License Number StateSC

VIII. Authorized Official

Name: MR. MARK R. FAWCETT
Title or Position: SVP & TREASURER
Credential:
Phone: 781-699-9000