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General NPI Number Information
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NPI Number | 1558418921
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Entity Type | Organization
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Legal Business Name | DOUGLASVILLE NEPHROLOGY & HTN CLINIC
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Dates
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Enumeration Date | 01/05/2007
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Last Update Date | 02/14/2024
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Provider Practice Location Address
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Address Line | 6488 SPRING ST STE 100
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City | DOUGLASVILLE
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State | GA
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Zip | 30134-1895
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Country | US
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Telephone | 770-489-4978
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Fax | 770-489-5279
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Provider Business Mailing Address
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Address Line | 6488 SPRING ST STE 100
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City | DOUGLASVILLE
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State | GA
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Zip | 30134-1895
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Country | US
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Telephone | 770-489-4978
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Fax | 770-489-5279
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | DOREEN SMALLS
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Credential |
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Telephone | 770-489-4978
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 40859
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 207RN0300X
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Taxonomy Name | Nephrology Physician
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License Number | 40859
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License Number State | GA
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