MEDICARE: TERRELL DIALYSIS CENTER, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QE0700X	End-Stage Renal Disease (ESRD) Treatment Clinic/Center

General Provider Information

NPI Number	:	1003193053
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TERRELL DIALYSIS CENTER, LLC

Provider Business Mailing Address
First Line	:	4810 W ILLINOIS AVE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75211-6501
Country	:	US
Telephone Number	:	214-467-3788
Fax Number	:	214-467-3789

Provider Business Practice Location Address
First Line	:	4810 W ILLINOIS AVE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75211-6501
Country	:	US
Telephone Number	:	214-467-3788
Fax Number	:	214-467-3789

Authorized Official
Title or Position	:	TREASURER
Name	:	MARK R. FAWCETT
Credential	:
Telephone Number	:	781-699-9000

Provider Enumeration Date	:	11/04/2011
Last Update Date	:	11/04/2011

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