1083670988 NPI number — SOUTHEASTERN RENAL DIALYSIS L.C.

Table of content: (NPI 1083670988)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083670988 NPI number — SOUTHEASTERN RENAL DIALYSIS L.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHEASTERN RENAL DIALYSIS L.C.
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:
Provider Other Organization Name Type Code:
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:
1083670988
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/16/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
507 S WHITE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MT PLEASANT
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52641-2625
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1419 MORGAN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KEOKUK
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52632-4027
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-524-2105
Provider Business Practice Location Address Fax Number:
319-524-2188
Provider Enumeration Date:
04/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LIECHTY
Authorized Official First Name:
MARY
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
319-385-6728

Provider Taxonomy Codes

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

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

  • Identifier: 0625178 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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