11D0952596 CLIA NUMBER - FAYETTEVILLE DIALYSIS

Laboratory Demographics

CLIA Number: 11D0952596

Facility Name: FAYETTEVILLE DIALYSIS

Facility Address:
1279 HIGHWAY 54 WEST, SUITE 110
FAYETTEVILLE, GA
ZIP 30214
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Facility Phone Number: 678 817-9328

Facility Type: End Stage Renal Disease Dialysis Facility

Certificate Type: Waiver

NPI Number: 1073056933

Taxonomy: 1223P0221X - Dentist
An age-defined specialty that provides both primary and comprehensive preventive and therapeutic oral health care for infants and children through adolescence, including those with special health care needs.

CLIA Record

Field Name	Field Value
CLIA Number	11D0952596
LAB Type	End Stage Renal Disease Dialysis Facility
Facility Name	FAYETTEVILLE DIALYSIS
Street	1279 HIGHWAY 54 WEST, SUITE 110
City	FAYETTEVILLE
State	GA
ZIP	30214
Phone	678 817-9328
CertificateType	4
CertificateEffectiveDate	10/16/2022
CertificateExpirationDate	10/15/2024
FacilityType	Waiver

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This page was last updated on: 4/23/2024