Healthcare Provider Details

I. General information

NPI: 1508037011
Provider Name (Legal Business Name): DIALYSIS ACCESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2008
Last Update Date: 10/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

357 AVE HOSTOS OFFICE PARK II SUITE 203
MAYAGUEZ PR
00680-1507
US

IV. Provider business mailing address

357 AVE HOSTOS OFFICE PARK II SUITE 203
MAYAGUEZ PR
00680-1507
US

V. Phone/Fax

Practice location:
  • Phone: 847-388-2065
  • Fax: 866-720-9740
Mailing address:
  • Phone: 847-388-2065
  • Fax: 866-720-9740

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: MS. LYSA JACKS
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 847-388-2065