Healthcare Provider Details

I. General information

NPI: 1003445511
Provider Name (Legal Business Name): FREEPORT DIALYSIS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2020
Last Update Date: 05/31/2023
Certification Date: 05/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

326 S BRAZOSPORT BLVD
FREEPORT TX
77541-4540
US

IV. Provider business mailing address

450 THIS WAY ST STE B
LAKE JACKSON TX
77566-5152
US

V. Phone/Fax

Practice location:
  • Phone: 979-297-2220
  • Fax:
Mailing address:
  • Phone: 979-297-2220
  • Fax: 979-297-3330

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: DR. MANAF ALROUMOH
Title or Position: CEO
Credential: MD
Phone: 979-297-2220