MEDICARE: SOUTHWEST KIDNEY DIALYSIS, 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	3546	AZ

General Provider Information

NPI Number	:	1053360925
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHWEST KIDNEY DIALYSIS, LLC

Provider Business Mailing Address
First Line	:	2149 E WARNER RD
Second Line	:	SUITE 101
City	:	TEMPE
State	:	AZ
Zip	:	85284-3494
Country	:	US
Telephone Number	:	480-610-6100
Fax Number	:

Provider Business Practice Location Address
First Line	:	20325 N 51ST AVE
Second Line	:	BUILDING 11 SUITE 184
City	:	GLENDALE
State	:	AZ
Zip	:	85308-5674
Country	:	US
Telephone Number	:	623-533-3836
Fax Number	:	623-533-4033

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	MR. JEFFERY WEINTRAUB
Credential	:
Telephone Number	:	480-610-6100

Provider Enumeration Date	:	05/09/2006
Last Update Date	:	09/24/2007

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