=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801263009
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NULIFE DIALYSIS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/24/2015
-----------------------------------------------------
Last Update Date | 08/24/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4805 NW 183RD ST
-----------------------------------------------------
City | MIAMI GARDENS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33055-2955
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-952-4925
-----------------------------------------------------
Fax | 786-657-2801
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4805 NW 183 STREET
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33055
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-952-4925
-----------------------------------------------------
Fax | 786-657-2801
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | LAZARO B RAMOS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 786-414-9291
-----------------------------------------------------
=====================================================
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 |
-----------------------------------------------------