=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437613916
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PREMIER HOME DIALYSIS SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/29/2019
-----------------------------------------------------
Last Update Date | 01/29/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20118 N 67TH AVE STE 300-527
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85308-4621
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-448-5411
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20118 N 67TH AVE STE 300-527
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85308-4621
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-448-5411
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FOUNDER/CEO
-----------------------------------------------------
Name | MR. STEPHEN ERIK THOMPSON
-----------------------------------------------------
Credential | EMT/CPR/FF I&II
-----------------------------------------------------
Telephone | 602-448-5411
-----------------------------------------------------
=====================================================
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 |
-----------------------------------------------------