=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104172527
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UNIVERSAL DIALYSIS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/03/2012
-----------------------------------------------------
Last Update Date | 12/08/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12919 SOUTHWEST FWY #138
-----------------------------------------------------
City | STAFFORD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77477-4122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-203-8053
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12919 SOUTHWEST FWY #138
-----------------------------------------------------
City | STAFFORD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77477-4122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MS. DOLORES CELESTINE
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 713-203-8053
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------