=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265823918
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIALYSIS AT HOME
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/16/2015
-----------------------------------------------------
Last Update Date | 03/27/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11638 S WESTERN AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60643-4730
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 224-735-3638
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11638 S WESTERN AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60643-4730
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 224-735-3638
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SHAHIDA M KHAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 847-401-6079
-----------------------------------------------------
=====================================================
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 | IL
-----------------------------------------------------