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Harris Dialysis, LLC

Details

Name: Harris Dialysis, LLC
Jurisdiction: Alabama
Legal type: Foreign Limited Liability Company
Status: Exists
Date of registration: 21 Mar 2012 (13 years ago) (Companies founded in March 2012)
Entity Number: 000-030-570
Register Number: 000030570
ZIP code: 36104 (Companies in Montgomery, 36104)
County: Montgomery
Place of Formation: Delaware
Principal Address: 1551 WEWATTA STREETDENVER, CO 80202
Principal Mailing Address: 601 HAWAII STREETEL SEGUNDO, CA 90245
Registered Office Street Address: 641 SOUTH LAWRENCE STREETMONTGOMERY, AL 36104

National Provider Identifier

NPI Enumeration Date Last Update Date Mailing Address Practice Location Address
1225399835 2012-05-31 2024-02-12 5200 VIRGINIA WAY, L&C DEPT, BRENTWOOD, TN, 370277569, US 16236 LUCAS FERRY RD, ATHENS, AL, 356113931, US

Contacts

Phone +1 615-320-4268
Fax 8772380567
Phone +1 256-233-3965
Fax 2562333184

Authorized person

Name SAMUEL WEY
Role VP LICENSURE & CERTIFICATION
Phone 6153416641

Taxonomy

Taxonomy Code 261QE0700X - End-Stage Renal Disease (ESRD) Treatment Clinic/Center
License Number S4202
State AL
Is Primary Yes

Other Provider Identifiers

Issuer MEDICAID
Number 137273
State AL

Commercial and government entity program

CAGE number Status Type Established CAGE Update Date CAGE Expiration SAM Expiration
6U0H6 Active Non-Manufacturer 2013-01-17 2023-02-12 2027-01-17 2023-02-12

Contact Information

POC DONNA BRAWELY
Phone +1 253-382-1493
Fax +1 888-577-9570
Address 16236 LUCAS FERRY RD, ATHENS, AL, 35611 3931, UNITED STATES

Ownership of Offeror Information

Highest Level Owner Information not Available
Immediate Level Owner
Vendor Certified 2022-01-17
CAGE number 45JM2
Company Name DAVITA INC.
CAGE Last Updated 2024-03-29
List of Offerors (0) Information not Available

Agent

Name Role Address
CORPORATION SERVICE COMPANY INC Agent 251 LITTLE FALLS DRIVEWILMINGTON, DE 19808

Date of last update: 30 Jul 2024

Sources: Alabama Secretary of State