Healthcare Provider Details

I. General information

NPI: 1255906343
Provider Name (Legal Business Name): PHYSICIANS CHOICE DIALYSIS OF BETHANY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2021
Last Update Date: 05/21/2021
Certification Date: 05/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2202 N. FLAMINGO AVENUE
BETHANY OK
73008
US

IV. Provider business mailing address

211 COMMERCE CT STE 104
POTTSTOWN PA
19464-3483
US

V. Phone/Fax

Practice location:
  • Phone: 610-495-8900
  • Fax:
Mailing address:
  • Phone: 302-290-7408
  • 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

VIII. Authorized Official

Name: KELLY SMITH
Title or Position: DIRECTOR
Credential:
Phone: 302-290-7408