Healthcare Provider Details

I. General information

NPI: 1144829748
Provider Name (Legal Business Name): AQUA DIALYSIS FRANK AVENUE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2020
Last Update Date: 09/10/2024
Certification Date: 09/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 W FRANK AVE
LUFKIN TX
75904-3314
US

IV. Provider business mailing address

1245 SOUTHRIDGE CT STE 102
HURST TX
76053-4390
US

V. Phone/Fax

Practice location:
  • Phone: 936-238-3583
  • Fax:
Mailing address:
  • Phone: 682-429-4508
  • Fax: 346-214-6368

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: ALICIA CARTER
Title or Position: REVENUE CYCLE DIRECTOR
Credential:
Phone: 682-429-4508