Healthcare Provider Details

I. General information

NPI: 1952676033
Provider Name (Legal Business Name): NEW SMYRNA BEACH DIALYSIS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2012
Last Update Date: 03/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

821 STATE ROAD 44
NEW SMYRNA BEACH FL
32168-7271
US

IV. Provider business mailing address

821 STATE ROAD 44
NEW SMYRNA BEACH FL
32168-7271
US

V. Phone/Fax

Practice location:
  • Phone: 386-409-8855
  • Fax: 386-409-8755
Mailing address:
  • Phone: 386-409-8855
  • Fax: 386-409-8755

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

VIII. Authorized Official

Name: MR. JOHN J. MCDONOUGH
Title or Position: COO
Credential:
Phone: 978-922-3080