MEDICARE: COMMONWEALTH DIALYSIS CENTER HOME HEMO,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	:	1154654317
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMONWEALTH DIALYSIS CENTER HOME HEMO,LLC

Provider Business Mailing Address
First Line	:	601 N 99TH ST
Second Line	:	SUITE 110
City	:	WAUWATOSA
State	:	WI
Zip	:	53226-4339
Country	:	US
Telephone Number	:	414-755-6330
Fax Number	:

Provider Business Practice Location Address
First Line	:	2100 CENTRAL AVE
Second Line	:	SUITE 201
City	:	BOULDER
State	:	CO
Zip	:	80301-2838
Country	:	US
Telephone Number	:	303-785-7523
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MR. HERBERT S. LAWSON
Credential	:
Telephone Number	:	303-785-7521

Provider Enumeration Date	:	09/04/2009
Last Update Date	:	09/04/2009

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