Provider Demographics
NPI:1073560645
Name:NRA-BAMBERG, SOUTH CAROLINA, LLC
Entity type:Organization
Organization Name:NRA-BAMBERG, SOUTH CAROLINA, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BLANTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-699-9000
Mailing Address - Street 1:2046 MAIN HWY
Mailing Address - Street 2:
Mailing Address - City:BAMBERG
Mailing Address - State:SC
Mailing Address - Zip Code:29003-1082
Mailing Address - Country:US
Mailing Address - Phone:803-245-1775
Mailing Address - Fax:803-245-9390
Practice Address - Street 1:2046 MAIN HWY
Practice Address - Street 2:
Practice Address - City:BAMBERG
Practice Address - State:SC
Practice Address - Zip Code:29003-1082
Practice Address - Country:US
Practice Address - Phone:803-245-1775
Practice Address - Fax:803-245-9390
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FRESENIUS MEDICAL CARE HOLDINGS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-28
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCERD-136261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC42D1013180OtherCLIA CERTIFICATE OF WAIVE
SCERD136Medicaid
SC42-2594Medicare Oscar/Certification