MEDICARE: FILLMORE DIALYSIS, 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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1659915882
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FILLMORE DIALYSIS, LLC

Provider Business Mailing Address
First Line	:	5200 VIRGINIA WAY
Second Line	:	L&C DEPT
City	:	BRENTWOOD
State	:	TN
Zip	:	37027-7569
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4555 ATLANTA HWY STE M
Second Line	:
City	:	LOGANVILLE
State	:	GA
Zip	:	30052-2646
Country	:	US
Telephone Number	:	770-466-2582
Fax Number	:	770-466-3062

Authorized Official
Title or Position	:	VP LICENSURE & CERTIFICATION
Name	:	SAMUEL T WEY
Credential	:
Telephone Number	:	615-341-6641

Provider Enumeration Date	:	10/31/2019
Last Update Date	:	12/23/2025

Similar Medicare Providers

1679428908 — FELICIA KWASHIE
Practice Location Address:

3080 COTTAGE DR
LOGANVILLE, GA
30052-5495

Practice Phone: 508-271-5565
Practice Fax:

1912656885 — MRS. SHARIKA D GARDNER SPATES LCSW
Practice Location Address:

3753 OKEFENOKEE RDG
LOGANVILLE, GA
30052-3382

Practice Phone: 404-216-2808
Practice Fax:

1679577936 — DR. PONNIE DAVIS POISAL DMD
Practice Location Address:

3973 ATLANTA HWY , STE 100
LOGANVILLE, GA
30052-3750

Practice Phone: 770-466-3114
Practice Fax: 770-466-3777

1174521868 — MR. THOMAS CHRISTOPHER WILSON PT
Practice Location Address:

3455 HIGHWAY 81 SOUTH
LOGANVILLE, GA
30052-3918

Practice Phone: 678-635-8280
Practice Fax: 678-635-8285

1609868298 — MS. THERESA G. GOODMAN NP-C
Practice Location Address:

605 ASHTON MANOR DR
LOGANVILLE, GA
30052-5330

Practice Phone: 216-406-2466
Practice Fax: 770-554-1621

1497748586 — KAREN DETLEFSEN PRICE MA CCC/SLP
Practice Location Address:

200 IVY CREEK DR
LOGANVILLE, GA
30052-3119

Practice Phone: 404-883-6913
Practice Fax: 770-554-0156

Directions to “FILLMORE DIALYSIS, LLC ” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

Copyright © 2007-2026 (Powered by Swiss Vault Engine), all rights reserved. HIPAA liability, trademark, document use and software licensing rules apply. All registered trademarks, used in the content, are the property of their owners. Your interactions with this site are in accordance with our Terms of Use and Privacy Policy.