Healthcare Provider Details

I. General information

NPI: 1184132425
Provider Name (Legal Business Name): INNOVATIVE DIALYSIS SOLUTIONS AT HOME OF DEVINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2018
Last Update Date: 05/07/2022
Certification Date: 05/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 S. UPSON DRIVE
DEVINE TX
78016
US

IV. Provider business mailing address

915 S LAREDO ST STE 200
SAN ANTONIO TX
78204-3211
US

V. Phone/Fax

Practice location:
  • Phone: 830-541-5372
  • Fax: 830-267-8110
Mailing address:
  • Phone: 210-277-1418
  • 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: MR. MARK NAIL
Title or Position: BUSINESS MANAGER
Credential:
Phone: 972-626-1117