1043491194 NPI number — GARFIELD DIALYSIS VENTURE LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043491194 NPI number — GARFIELD DIALYSIS VENTURE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GARFIELD DIALYSIS VENTURE 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:
HUMBOLDT RIDGE DIALYSIS CENTER
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:
1043491194
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/27/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2514 S 102ND ST
Provider Second Line Business Mailing Address:
SUITE 120
Provider Business Mailing Address City Name:
WEST ALLIS
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53227-2142
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-777-5200
Provider Business Mailing Address Fax Number:
414-777-5210

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2211 N HUMBOLDT BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53212-3507
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-336-7200
Provider Business Practice Location Address Fax Number:
414-777-5210
Provider Enumeration Date:
11/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LUCKENBILL
Authorized Official First Name:
BARRY
Authorized Official Middle Name:
LEE
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
414-777-5200

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2024 www.npivalidator.com