| Name: | Harris Dialysis, LLC |
| Jurisdiction: | Alabama |
| Legal type: | Foreign Limited Liability Company |
| Status: | Exists |
| Date of registration: | 21 Mar 2012 (13 years ago) |
| Entity Number: | 000-030-570 |
| Register Number: | 000030570 |
| 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 |
| Registered Office Street Address ZIP Code: | 36104 |
| 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 | |||||||||||||||||||||||||||||
|
|||||||||||||||||||||||||||||||||
| 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 |
| 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 | |||||||||||||||||||||||
|
|||||||||||||||||||||||||||||
| 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 |
|---|
| 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
