Provider Demographics
NPI:1215109087
Name:VALDOSTA KIDNEY CLINIC, LLC
Entity type:Organization
Organization Name:VALDOSTA KIDNEY CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIA ESTER
Authorized Official - Middle Name:
Authorized Official - Last Name:CHIANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-244-6544
Mailing Address - Street 1:PO BOX 2267
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31604-2267
Mailing Address - Country:US
Mailing Address - Phone:229-244-6544
Mailing Address - Fax:229-241-9744
Practice Address - Street 1:410 COWART AVE
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-2622
Practice Address - Country:US
Practice Address - Phone:229-244-6544
Practice Address - Fax:229-241-9744
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-01
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA054594174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GRP6735OtherMEDICARE ID
GADC4801OtherRAILROAD MEDICARE GROUP
GAF67367Medicare UPIN