MEDICARE: ARA-SOUTH LABURNUM 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

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	:	1093856643
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ARA-SOUTH LABURNUM DIALYSIS LLC

Provider Business Mailing Address
First Line	:	4817 S LABURNUM AVE
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23231-2713
Country	:	US
Telephone Number	:	804-222-7718
Fax Number	:	804-222-7719

Provider Business Practice Location Address
First Line	:	4817 S LABURNUM AVE
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23231-2713
Country	:	US
Telephone Number	:	804-222-7718
Fax Number	:	804-222-7719

Authorized Official
Title or Position	:	CHIEF NURSING OFFICER
Name	:	SARA BRADY
Credential	:
Telephone Number	:	208-371-7878

Provider Enumeration Date	:	02/08/2007
Last Update Date	:	01/11/2023

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