=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164164182
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PREMIER DIALYSIS SERVICE CENTRAL MICHIGAN LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/11/2022
-----------------------------------------------------
Last Update Date | 04/11/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13044 MONINGTON CT
-----------------------------------------------------
City | FENTON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48430-1191
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-223-1938
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13044 MONINGTON CT
-----------------------------------------------------
City | FENTON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48430-1191
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-223-1938
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JOSHUA DIPZINSKI
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 810-223-1938
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QE0700X
-----------------------------------------------------
Taxonomy Name | End-Stage Renal Disease (ESRD) Treatment Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------