1548032360 NPI number — DIALYSIS CARE CENTER LAGRANGE 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 1548032360 NPI number — DIALYSIS CARE CENTER LAGRANGE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIALYSIS CARE CENTER LAGRANGE 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:
1548032360
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/25/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3134
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JOLIET
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60434-3134
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-714-7170
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
109 PARKER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAGRANGE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30240-6436
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-350-4967
Provider Business Practice Location Address Fax Number:
706-350-4879
Provider Enumeration Date:
10/25/2023

Additional Information

Authorized Official

Authorized Official Last Name:
ALAUSA
Authorized Official First Name:
MORUFU
Authorized Official Middle Name:
OLATUNJI
Authorized Official Title or Position:
MEDICAL OFFICER
Authorized Official Telephone Number:
815-741-6830

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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