Provider Demographics
NPI:1902168628
Name:FRESENIUS MEDICAL CARE BERKELEY LAKE, LLC
Entity Type:Organization
Organization Name:FRESENIUS MEDICAL CARE BERKELEY LAKE, LLC
Other - Org Name:FRESENIUS MEDICAL CARE BERKELEY LAKE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BLANTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-699-9000
Mailing Address - Street 1:3870 PEACHTREE INDUSTRIAL BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-1423
Mailing Address - Country:US
Mailing Address - Phone:770-495-7942
Mailing Address - Fax:770-495-7943
Practice Address - Street 1:3870 PEACHTREE INDUSTRIAL BLVD STE 110
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-1423
Practice Address - Country:US
Practice Address - Phone:770-495-7942
Practice Address - Fax:770-495-7943
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FRESENIUS MEDICAL CARE HOLDINGS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-06-08
Last Update Date:2023-10-18
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
GA003132241AMedicaid