1437261112 NPI number — ARA-TITUSVILLE DIALYSIS 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 1437261112 NPI number — ARA-TITUSVILLE DIALYSIS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ARA-TITUSVILLE DIALYSIS 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:
TITUSVILLE DIALYSIS AND KIDNEY 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:
1437261112
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/10/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
801 GARDEN ST STE B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TITUSVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32796-3408
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-567-0122
Provider Business Mailing Address Fax Number:
321-567-0124

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
801 GARDEN ST STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TITUSVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32796-3408
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-567-0122
Provider Business Practice Location Address Fax Number:
321-567-0124
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BRADY
Authorized Official First Name:
SARA
Authorized Official Middle Name:
ANNE
Authorized Official Title or Position:
CHIEF NURSING OFFICER
Authorized Official Telephone Number:
208-371-7878

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)

  • Identifier: 890112100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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