Geographic variation of pre-end-stage renal disease (pre-ESRD) nephrology care has not been studied across the United States. Here we sought to identify geographic differences in pre-ESRD care, assess for county-level geographic and sociodemographic risk factors, and correlate with patient outcomes using facility-level mortality. Patients from 5387 dialysis facilities across the United States from 2007 to 2010 were included from the Dialysis Facility Report. Marginal generalized estimating equations were used for modeling with geographic cluster analysis to detect clusters of facilities with low rates of pre-ESRD care. On average, 67% of patients received pre-ESRD care in the United States but with significant variability across regions ranging from 3 to 99%. Five geographic clusters of facilities with low rates of pre-ESRD care were the metropolitan areas of San Francisco, Los Angeles, Chicago, Miami, and Baltimore, along with Southern states along the Mississippi River. Dialysis facilities with the lowest rates of pre-ESRD care were more likely to be located in urban counties with high African-American populations and low educational attainment. A 10% higher proportion of patients receiving pre-ESRD care was associated with 1.3% lower patient mortality as reflected by facility-level mortality. Thus, geographic and sociodemographic factors can be used to design quality improvement initiatives to increase access to nephrology care nationwide and improve patient outcomes.