11D1008399 CLIA NUMBER - FORT VALLEY DIALYSIS CENTER, LLC

Laboratory Demographics

CLIA Number: 11D1008399

Facility Name: FORT VALLEY DIALYSIS CENTER, LLC

Facility Address:
135 AVERA DRIVE
FORT VALLEY, GA
ZIP 31030
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Facility Phone Number: 478 827-0776

Facility Type: End Stage Renal Disease Dialysis Facility

Certificate Type: Waiver

NPI Number: 1235649765

Taxonomy: 261QE0700X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	11D1008399
LAB Type	End Stage Renal Disease Dialysis Facility
Facility Name	FORT VALLEY DIALYSIS CENTER, LLC
Street	135 AVERA DRIVE
City	FORT VALLEY
State	GA
ZIP	31030
Phone	478 827-0776
CertificateType	4
CertificateEffectiveDate	1/21/2023
CertificateExpirationDate	1/20/2025
FacilityType	Waiver

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