1336314319 NPI number — LIBERTY DIALYSIS - LAREDO ACUTES 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 1336314319 NPI number — LIBERTY DIALYSIS - LAREDO ACUTES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIBERTY DIALYSIS - LAREDO ACUTES 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:
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:
1336314319
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/03/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7650 SE 27TH ST
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
MERCER ISLAND
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98040-3060
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:
1127 BROADWAY
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98402-3519
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-236-5001
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/29/2008

Additional Information

Authorized Official

Authorized Official Last Name:
PARDO
Authorized Official First Name:
RYAN
Authorized Official Middle Name:
B
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
206-236-5001

Provider Taxonomy Codes

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

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





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