Healthcare Provider Details

I. General information

NPI: 1154654317
Provider Name (Legal Business Name): COMMONWEALTH DIALYSIS CENTER HOME HEMO,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2009
Last Update Date: 09/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 CENTRAL AVE SUITE 201
BOULDER CO
80301-2838
US

IV. Provider business mailing address

601 N 99TH ST SUITE 110
WAUWATOSA WI
53226-4339
US

V. Phone/Fax

Practice location:
  • Phone: 303-785-7523
  • Fax:
Mailing address:
  • Phone: 414-755-6330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0700X
TaxonomyEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MR. HERBERT S. LAWSON
Title or Position: CEO
Credential:
Phone: 303-785-7521