Healthcare Provider Details

I. General information

NPI: 1700162880
Provider Name (Legal Business Name): FMS MIDWEST DIALYSIS CENTERS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2011
Last Update Date: 10/18/2023
Certification Date: 10/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1208 E HARTFORD AVE
PONCA CITY OK
74601-2017
US

IV. Provider business mailing address

1208 E HARTFORD AVE
PONCA CITY OK
74601-2017
US

V. Phone/Fax

Practice location:
  • Phone: 580-718-9357
  • Fax: 580-718-9421
Mailing address:
  • Phone: 580-718-9357
  • Fax: 580-718-9421

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: BARRY L. BLANTON
Title or Position: VICE PRESIDENT
Credential:
Phone: 781-699-9000