MEDICARE: FORT SMITH DIALYSIS SUPPLY COMPANY

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)

General Provider Information

NPI Number	:	1518962760
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FORT SMITH DIALYSIS SUPPLY COMPANY

Provider Business Mailing Address
First Line	:	1506 DODSON AVE
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72901-5128
Country	:	US
Telephone Number	:	479-709-6828
Fax Number	:	479-709-7453

Provider Business Practice Location Address
First Line	:	1506 DODSON AVE
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72901-5128
Country	:	US
Telephone Number	:	479-709-6828
Fax Number	:	479-709-7453

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MRS. PAMELA SUE CLARK
Credential	:	RN,CNN
Telephone Number	:	479-709-6828

Provider Enumeration Date	:	06/15/2005
Last Update Date	:	08/22/2020

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