Healthcare Provider Details

I. General information

NPI: 1962242552
Provider Name (Legal Business Name): PACIFIC NORTHWEST RENAL SERVICES, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2024
Last Update Date: 05/30/2024
Certification Date: 05/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37139 HIGHWAY 26
SANDY OR
97055-7271
US

IV. Provider business mailing address

37139 HIGHWAY 26
SANDY OR
97055-7271
US

V. Phone/Fax

Practice location:
  • Phone: 503-826-1352
  • Fax: 505-826-0810
Mailing address:
  • Phone: 503-826-1352
  • Fax: 505-826-0810

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 BLANTON
Title or Position: VP
Credential:
Phone: 214-445-3010