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General NPI Number Information
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NPI Number | 1720187248
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Entity Type | Organization
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Legal Business Name | GEM STATE REGIONAL DIALYSIS CENTER
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Dates
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Enumeration Date | 09/21/2006
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Last Update Date | 09/11/2007
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Provider Practice Location Address
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Address Line | 2225 TETON PLZ STE A
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City | IDAHO FALLS
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State | ID
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Zip | 83404-6494
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Country | US
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Telephone | 208-522-4831
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Fax | 208-529-4189
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Provider Business Mailing Address
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Address Line | PO BOX 27071
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City | SALT LAKE CITY
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State | UT
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Zip | 84127-0071
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Country | US
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Telephone | 801-581-8578
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Fax | 208-529-4189
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Authorized Official
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Title or Position | PROGRAM ADMINISTRATOR
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Name | MR. STEVEN L HEMMING
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Credential |
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Telephone | 801-581-8573
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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 | ID DOESN'T ISSUE ONE
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License Number State | ID
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