MEDICARE: LIBERTY DIALYSIS - DAVIS COUNTY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QE0700X	End-Stage Renal Disease (ESRD) Treatment Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	462537	OTHER	UT	PTAN

General Provider Information

NPI Number	:	1841487881
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIBERTY DIALYSIS - DAVIS COUNTY LLC

Provider Business Mailing Address
First Line	:	2132 N ROBINS DR STE 120
Second Line	:
City	:	LAYTON
State	:	UT
Zip	:	84041-7059
Country	:	US
Telephone Number	:	801-779-6104
Fax Number	:	801-779-6106

Provider Business Practice Location Address
First Line	:	2132 N ROBINS DR STE 120
Second Line	:
City	:	LAYTON
State	:	UT
Zip	:	84041-7059
Country	:	US
Telephone Number	:	801-779-6104
Fax Number	:	801-779-6106

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

Provider Enumeration Date	:	10/03/2007
Last Update Date	:	10/17/2023

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