Fidelity Home Dialysis Corporation

Primary specialty

End-Stage Renal Disease (ESRD) Treatment Clinic/CenterTaxonomy code 261QE0700X

Legal business name

FIDELITY HOME DIALYSIS CORPORATION

Practice address

1230 Johnson Ferry PL Ste H30
Marietta, GA 30068-2058

Phone

(678) 742-8563

Fax

(678) 742-8178

NPI assigned

Feb 4, 2015

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Steve Ficklin

Title

Administrator

Phone

(501) 217-3888

Specialties & licenses 1

Addresses

Other identifiers 1

Electronic endpoints 1

Medicare fee-for-service enrollment

Enrolled in GA

Enrollment records 1

End-stage renal disease facility certification: CCN 852595

Legal name

Fidelity Home Dialysis

Certification status

Active

Provider type (POS)

End-stage renal disease facility

Participating since

Mar 8, 2023

Last certification

Feb 9, 2023

Ownership / control type

For Profit

Facility address

1230 Johnson Ferry PL Suite H30
Marietta, GA 30068

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1423008000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1653955200000",
    "number": "1447640917",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1230 JOHNSON FERRY PL STE H30",
            "city": "MARIETTA",
            "state": "GA",
            "postal_code": "300682058",
            "telephone_number": "678-742-8563",
            "fax_number": "678-742-8178"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1230 JOHNSON FERRY PL STE H30",
            "city": "MARIETTA",
            "state": "GA",
            "postal_code": "300682058",
            "telephone_number": "678-742-8563",
            "fax_number": "678-742-8178"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FIDELITY HOME DIALYSIS CORPORATION",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-02-04",
        "last_updated": "2022-05-31",
        "certification_date": "2022-05-31",
        "status": "A",
        "authorized_official_last_name": "FICKLIN",
        "authorized_official_first_name": "STEVE",
        "authorized_official_title_or_position": "ADMINISTRATOR",
        "authorized_official_telephone_number": "501-217-3888"
    },
    "taxonomies": [
        {
            "code": "261QE0700X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, End-Stage Renal Disease (ESRD) Treatment",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE",
            "identifier": "042593",
            "state": "AR"
        }
    ],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "N/A",
            "affiliation": "N",
            "use": "DIRECT",
            "useDescription": "Direct",
            "contentType": "CSV",
            "contentTypeDescription": "CSV",
            "address_1": "1230 Johnson Ferry Pl Ste H30",
            "city": "Marietta",
            "state": "GA",
            "country_code": "US",
            "postal_code": "300682058",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

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• End-Stage Renal Disease (ESRD) Treatment Clinic/Center in Marietta, GA
• Providers in Marietta, GA by specialty
• End-Stage Renal Disease (ESRD) Treatment Clinic/Center in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 31, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.