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General NPI Number Information
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NPI Number | 1417016551
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Entity Type | Organization
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Legal Business Name | SOUTH FULTON DIALYSIS CENTER LLC
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Dates
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Enumeration Date | 12/06/2006
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Last Update Date | 07/21/2017
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Provider Practice Location Address
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Address Line | 3268 GREENBRIAR PKWY SW
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City | ATLANTA
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State | GA
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Zip | 30331-2604
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Country | US
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Telephone | 404-997-6700
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Fax | 404-997-6710
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Provider Business Mailing Address
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Address Line | 1151 CLEVELAND AVENUE SUITE A/B
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City | EAST POINT
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State | GA
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Zip | 30344-3618
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Country | US
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Telephone | 404-669-9669
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Fax | 404-669-6998
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. BOB AGBOGU
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Credential |
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Telephone | 404-669-9669
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QE0700X
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Taxonomy Name | End-Stage Renal Disease (ESRD) Treatment Clinic/Center
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License Number | ESRD001133
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License Number State | GA
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