Provider Demographics
NPI:1215925375
Name:DEMOREST DIALYSIS FACILITY, L.L.C.
Entity type:Organization
Organization Name:DEMOREST DIALYSIS FACILITY, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING SPECIALIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:KRISTY
Authorized Official - Middle Name:W
Authorized Official - Last Name:DUNCAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-433-0683
Mailing Address - Street 1:PO BOX 6385
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30604-6385
Mailing Address - Country:US
Mailing Address - Phone:706-546-0083
Mailing Address - Fax:706-613-9205
Practice Address - Street 1:1507 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:DEMOREST
Practice Address - State:GA
Practice Address - Zip Code:30535-4555
Practice Address - Country:US
Practice Address - Phone:706-433-0683
Practice Address - Fax:706-369-1478
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-12
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAESRD001213261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA885141164AMedicaid
GA112713Medicare ID - Type Unspecified