MEDICARE: SAMARITAN DIALYSIS DME, 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	332BD1200X	Dialysis Equipment & Supplies (DME)	4193950	CO

General Provider Information

NPI Number	:	1295856920
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAMARITAN DIALYSIS DME, LLC

Provider Business Mailing Address
First Line	:	8125 W GRAND AVE
Second Line	:	STE LL
City	:	LAKEWOOD
State	:	CO
Zip	:	80123-1206
Country	:	US
Telephone Number	:	930-393-2962
Fax Number	:	303-972-9077

Provider Business Practice Location Address
First Line	:	8125 W GRAND AVE
Second Line	:	STE LL
City	:	LAKEWOOD
State	:	CO
Zip	:	80123-1206
Country	:	US
Telephone Number	:	930-393-2962
Fax Number	:	303-972-9077

Authorized Official
Title or Position	:	VP FINANCE TREASURER
Name	:	RONALD S STEVENS
Credential	:
Telephone Number	:	541-768-5004

Provider Enumeration Date	:	04/02/2007
Last Update Date	:	05/07/2010

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