=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629491501
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NXSTAGE ORLANDO SOUTH, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/28/2014
-----------------------------------------------------
Last Update Date | 07/17/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14522 LANDSTAR BLVD SUITE 102
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32824-6450
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-530-4006
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 350 MERRIMACK ST
-----------------------------------------------------
City | LAWRENCE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01843-1748
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-530-4006
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF OPERATIONS
-----------------------------------------------------
Name | JEFF MURRAY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 978-530-4006
-----------------------------------------------------
=====================================================
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 |
-----------------------------------------------------