MEDICARE: LIBERTY DIALYSIS - LAFAYETTE, 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	:	1245320639
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIBERTY DIALYSIS - LAFAYETTE, LLC

Provider Business Mailing Address
First Line	:	1020 N 18TH ST
Second Line	:
City	:	LAFAYETTE
State	:	IN
Zip	:	47904-2279
Country	:	US
Telephone Number	:	765-420-8000
Fax Number	:	765-420-8028

Provider Business Practice Location Address
First Line	:	1020 N 18TH ST
Second Line	:
City	:	LAFAYETTE
State	:	IN
Zip	:	47904-2279
Country	:	US
Telephone Number	:	765-420-8000
Fax Number	:	765-420-8028

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	BARRY L. BLANTON
Credential	:
Telephone Number	:	781-699-9000

Provider Enumeration Date	:	10/13/2006
Last Update Date	:	10/17/2023

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