MEDICARE: DIALYSIS CLINIC INC.

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1033142427
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIALYSIS CLINIC INC.

Provider Business Mailing Address
First Line	:	1916 BOGGS CREEK RD
Second Line	:
City	:	JEFFERSON CITY
State	:	MO
Zip	:	65101-5580
Country	:	US
Telephone Number	:	573-632-2633
Fax Number	:	573-632-4393

Provider Business Practice Location Address
First Line	:	1916 BOGGS CREEK RD
Second Line	:
City	:	JEFFERSON CITY
State	:	MO
Zip	:	65101-5580
Country	:	US
Telephone Number	:	573-632-2633
Fax Number	:	573-632-4393

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. DONOVAN SCHULTZ
Credential	:
Telephone Number	:	615-327-3061

Provider Enumeration Date	:	07/08/2006
Last Update Date	:	10/04/2023

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