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General NPI Number Information
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NPI Number | 1659745149
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Entity Type | Organization
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Legal Business Name | GRAND DIALYSIS SERVICES LLC
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Dates
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Enumeration Date | 11/20/2015
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Last Update Date | 08/11/2020
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Provider Practice Location Address
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Address Line | 500 N. HIATUS ROAD SUITE 105
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City | PEMBROKE PINES
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State | FL
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Zip | 33026
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Country | US
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Telephone | 954-962-9640
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Fax |
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Provider Business Mailing Address
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Address Line | 7765 JOHNSON ST
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City | PEMBROKE PINES
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State | FL
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Zip | 33024-6856
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Country | US
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Telephone | 954-962-9640
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | KEITH CARRASCO
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Credential |
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Telephone | 954-962-9640
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QE0700X
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Taxonomy Name | End-Stage Renal Disease (ESRD) Treatment Clinic/Center
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License Number | L15000170783
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License Number State | FL
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