MEDICARE: NRA-HOGANSVILLE, GEORGIA, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QE0700X	End-Stage Renal Disease (ESRD) Treatment Clinic/Center	PENDING	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	11D1054263	OTHER	GA	CLIA CERT OF WAIVER

General Provider Information

NPI Number	:	1497703078
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NRA-HOGANSVILLE, GEORGIA, LLC

Provider Business Mailing Address
First Line	:	1550 W. MCEWEN DRIVE
Second Line	:	SUITE 500
City	:	FRANKLIN
State	:	TN
Zip	:	37067-1731
Country	:	US
Telephone Number	:	615-661-1100
Fax Number	:	615-507-3300

Provider Business Practice Location Address
First Line	:	1002 WILLIAMS STREET
Second Line	:
City	:	HOGANSVILLE
State	:	GA
Zip	:	30230
Country	:	US
Telephone Number	:	706-637-4028
Fax Number	:	706-637-4382

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	MR. JON M. SUNDOCK
Credential	:
Telephone Number	:	615-507-3307

Provider Enumeration Date	:	05/05/2006
Last Update Date	:	02/10/2011

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