Provider Demographics
NPI:1285066936
Name:DOUGLASVILLE DIALYSIS SPA DDS
Entity type:Organization
Organization Name:DOUGLASVILLE DIALYSIS SPA DDS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FACILITY ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JENELL
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-903-4470
Mailing Address - Street 1:1380 VETERAMS MEMORIAL HWY SW
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126
Mailing Address - Country:US
Mailing Address - Phone:770-485-1773
Mailing Address - Fax:770-627-3202
Practice Address - Street 1:3138 GOLF RIDGE BLVD
Practice Address - Street 2:
Practice Address - City:DOUGLASVILE
Practice Address - State:GA
Practice Address - Zip Code:30135
Practice Address - Country:US
Practice Address - Phone:770-485-1773
Practice Address - Fax:770-627-3202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-05
Last Update Date:2016-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA112879Medicare Oscar/Certification