MEDICARE: CROWN DIALYSIS CLINIC, 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	:	1427211440
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CROWN DIALYSIS CLINIC, LLC.

Provider Business Mailing Address
First Line	:	12626 WOODFOREST BLVD # C
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77015-3425
Country	:	US
Telephone Number	:	713-301-2609
Fax Number	:	713-455-3387

Provider Business Practice Location Address
First Line	:	12626 WOODFOREST BLVD # C
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77015-3425
Country	:	US
Telephone Number	:	713-301-2609
Fax Number	:	713-455-3387

Authorized Official
Title or Position	:	CEO
Name	:	ALEXANDER ABE
Credential	:
Telephone Number	:	713-301-2609

Provider Enumeration Date	:	07/09/2008
Last Update Date	:	01/14/2010

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