Healthcare Provider Details

I. General information

NPI: 1710422845
Provider Name (Legal Business Name): PHOENIX DIALYSIS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2016
Last Update Date: 03/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 E. SOUTH ST.
WEIMAR TX
78962
US

IV. Provider business mailing address

PO BOX 127
FRESNO TX
77545-0127
US

V. Phone/Fax

Practice location:
  • Phone: 979-985-3700
  • Fax: 979-859-7154
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0700X
TaxonomyEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center
License Number110457
License Number StateTX

VIII. Authorized Official

Name: AUTUMN DAWSON
Title or Position: CEO
Credential:
Phone: 979-985-3700