Basic Information
| Provider Information | |||||||||
| NPI: | 1851302236 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HARBIN CLINIC, LLC | ||||||||
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| OtherOrganizationName: | HARBIN CLINIC DIALYSIS CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1825 MARTHA BERRY BLVD NW | ||||||||
| Address2: | |||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301651625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062955331 | ||||||||
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| Practice Location | |||||||||
| Address1: | 172 THREE RIVERS DR NE | ||||||||
| Address2: | |||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301614999 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062954641 | ||||||||
| FaxNumber: | 7062955379 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
| AuthorizedOfficialMiddleName: | FRANKLIN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 7062955331 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | ESRD001250 | GA | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
ID Information
| ID | Type | State | Issuer | Description | 51704028-001 | 01 | GA | BCBS OF GEORGIA | OTHER |