1124001169 NPI number — NORTH TEXAS DIALYSIS CLINIC, LLC

Table of content: (NPI 1124001169)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124001169 NPI number — NORTH TEXAS DIALYSIS CLINIC, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTH TEXAS DIALYSIS CLINIC, 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:
NORTH TEXAS DIALYSIS CLINIC, LLC
Provider Other Organization Name Type Code:
5
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:
1124001169
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4309 MESA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DENTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76207-3457
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
940-566-2701
Provider Business Mailing Address Fax Number:
940-382-2558

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1110 E CALIFORNIA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GAINESVILLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76240-4206
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
940-612-5555
Provider Business Practice Location Address Fax Number:
940-612-0735
Provider Enumeration Date:
11/23/2005

Additional Information

Authorized Official

Authorized Official Last Name:
CORPANY
Authorized Official First Name:
DAN
Authorized Official Middle Name:
MICHAEL
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
940-566-2701

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  007258 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 007258 . This is a "STATE LICENSE-ESRD FAC" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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