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General NPI Number Information
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NPI Number | 1720383219
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Entity Type | Organization
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Legal Business Name | JOHNSON DIALYSIS CENTER OF DAVIE FLORIDA LLC
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Dates
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Enumeration Date | 01/14/2011
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Last Update Date | 08/11/2020
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Provider Practice Location Address
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Address Line | 3105 NORTH UNIVERSITY DRIVE
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City | DAVIE
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State | FL
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Zip | 33024
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Country | US
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Telephone | 954-962-9640
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Fax | 954-962-9641
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Provider Business Mailing Address
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Address Line | 3105 N UNIVERSITY DR SUITE 3
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City | HOLLYWOOD
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State | FL
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Zip | 33024-2222
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Country | US
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Telephone | 954-962-9640
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Fax | 954-962-9641
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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 |
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License Number State |
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