1558792960 NPI number — HOLLYWOOD DIALYSIS, LLC

Table of content: (NPI 1558792960)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558792960 NPI number — HOLLYWOOD DIALYSIS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HOLLYWOOD 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:
FRESENIUS KIDNEY CARE HOLLYWOOD - BOULEVARD
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:
1558792960
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/23/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4000 HOLLYWOOD BLVD STE 175S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOLLYWOOD
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33021-6775
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-962-3100
Provider Business Mailing Address Fax Number:
954-962-3200

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4000 HOLLYWOOD BLVD STE 175S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOLLYWOOD
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33021-6775
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-962-3100
Provider Business Practice Location Address Fax Number:
954-962-3200
Provider Enumeration Date:
12/11/2013

Additional Information

Authorized Official

Authorized Official Last Name:
BLANTON
Authorized Official First Name:
BARRY
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
781-699-9000

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: 012350600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com