=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952999898
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HOPE KIDNEY CLINIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/06/2021
-----------------------------------------------------
Last Update Date | 01/06/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 460 NORTHSIDE CHEROKEE BLVD STE 430
-----------------------------------------------------
City | CANTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30115-8020
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-765-3766
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12460 CRABAPPLE RD # 202-158
-----------------------------------------------------
City | ALPHARETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30004-6602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-765-3766
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | SIRISHA GUTHIKONDA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 770-765-3766
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RN0300X
-----------------------------------------------------
Taxonomy Name | Nephrology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------