=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649357120
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KIDNEY CARE GROUP INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2006
-----------------------------------------------------
Last Update Date | 03/23/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3431 HIGHWAY 81
-----------------------------------------------------
City | LOGANVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30052-9138
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-957-6299
-----------------------------------------------------
Fax | 678-639-1634
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3431 HIGHWAY 81
-----------------------------------------------------
City | LOGANVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30052-9138
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-957-6299
-----------------------------------------------------
Fax | 678-639-1634
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MS. SAIMA BASHIR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 706-227-4075
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QE0700X
-----------------------------------------------------
Taxonomy Name | End-Stage Renal Disease (ESRD) Treatment Clinic/Center
-----------------------------------------------------
License Number | ESRD001252
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------