Provider Demographics
NPI:1912320631
Name:ATHENS RENAL CENTER LLC
Entity type:Organization
Organization Name:ATHENS RENAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF NURSING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SARA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:BRADY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-371-7878
Mailing Address - Street 1:2047 PRINCE AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-6033
Mailing Address - Country:US
Mailing Address - Phone:706-549-2133
Mailing Address - Fax:706-549-2134
Practice Address - Street 1:2047 PRINCE AVE
Practice Address - Street 2:SUITE A
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-6033
Practice Address - Country:US
Practice Address - Phone:706-549-2133
Practice Address - Fax:706-549-2134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-31
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003149145AMedicaid
GA003149145AMedicaid