MEDICARE: DIALYSIS AMERICA 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

General Provider Information

NPI Number	:	1962514778
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIALYSIS AMERICA GEORGIA, LLC

Provider Business Mailing Address
First Line	:	5825 GLENRIDGE DR NE
Second Line	:	BUILDING 3, SUITE 150
City	:	ATLANTA
State	:	GA
Zip	:	30328-5387
Country	:	US
Telephone Number	:	404-250-0058
Fax Number	:	404-847-9423

Provider Business Practice Location Address
First Line	:	5825 GLENRIDGE DR NE
Second Line	:	BUILDING 3, SUITE 150
City	:	ATLANTA
State	:	GA
Zip	:	30328-5387
Country	:	US
Telephone Number	:	404-250-0058
Fax Number	:	404-847-9423

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	BARRY L. BLANTON
Credential	:
Telephone Number	:	781-699-9000

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	10/14/2023

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