1093786782 NPI number — EAST PORTLAND PERITONEAL DIALYSIS CLINIC, LLC

Table of content: (NPI 1093786782)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093786782 NPI number — EAST PORTLAND PERITONEAL DIALYSIS CLINIC, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST PORTLAND PERITONEAL DIALYSIS CLINIC, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
U.S. RENAL CARE EAST PORTLAND HOME DIALYSIS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093786782
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/28/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5851 LEGACY CIR
Provider Second Line Business Mailing Address:
STE 900
Provider Business Mailing Address City Name:
PLANO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75024-5966
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-736-2700
Provider Business Mailing Address Fax Number:
214-736-2733

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10802 SE WASHINGTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97216-3118
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-254-4426
Provider Business Practice Location Address Fax Number:
503-254-4135
Provider Enumeration Date:
01/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WEINBERG
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
214-736-2700

Provider Taxonomy Codes

  • Taxonomy code: 261QE0700X , with the licence number:  394016 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 273929 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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