1235558073 NPI number — OSCEOLA DIALYSIS

Table of content: (NPI 1235558073)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235558073 NPI number — OSCEOLA DIALYSIS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OSCEOLA DIALYSIS
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:
ISD RENAL INC FKA DSI RENAL INC
Provider Other Organization Name Type Code:
5
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:
1235558073
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/09/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1332 W KEISER AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OSCEOLA
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72370-2919
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-563-4901
Provider Business Mailing Address Fax Number:
870-563-4959

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1423 PACIFIC AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98402-4203
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-382-1752
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/09/2014

Additional Information

Authorized Official

Authorized Official Last Name:
THIRY
Authorized Official First Name:
KENT
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
303-876-6000

Provider Taxonomy Codes

  • Taxonomy code: 261QE0700X , with the licence number:  04D0881442 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QE0700X , with the licence number: 1174578595 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 161527134 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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