MEDICARE: LITTLE ROCK DIALYSIS, INC.

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	:	1558473454
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LITTLE ROCK DIALYSIS, INC.

Provider Business Mailing Address
First Line	:	4275 E MCCAIN BLVD
Second Line	:
City	:	NORTH LITTLE ROCK
State	:	AR
Zip	:	72117-2516
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4275 E MCCAIN BLVD
Second Line	:
City	:	NORTH LITTLE ROCK
State	:	AR
Zip	:	72117-2516
Country	:	US
Telephone Number	:	501-945-9455
Fax Number	:

Authorized Official
Title or Position	:	TREASURER
Name	:	MARK FAWCETT
Credential	:
Telephone Number	:	781-402-9000

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	08/22/2020

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