=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932421427
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DAVIE KIDNEY CENTER OF WAKE FOREST UNIVERSITY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/24/2010
-----------------------------------------------------
Last Update Date | 02/09/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 190 INTERSTATE DR
-----------------------------------------------------
City | MOCKSVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27028-4195
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-753-1210
-----------------------------------------------------
Fax | 336-753-1529
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 7350
-----------------------------------------------------
City | TIFTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31793-7350
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-387-3528
-----------------------------------------------------
Fax | 229-386-2149
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING COORD.
-----------------------------------------------------
Name | MS. KIMBERLY AGEE-CLARK JOHNSON
-----------------------------------------------------
Credential | MBA
-----------------------------------------------------
Telephone | 229-387-3528
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QE0700X
-----------------------------------------------------
Taxonomy Name | End-Stage Renal Disease (ESRD) Treatment Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------