MEDICARE: DIALYSIS NEWCO 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	OTC4054	AZ

General Provider Information

NPI Number	:	1588947048
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIALYSIS NEWCO LLC

Provider Business Mailing Address
First Line	:	PO BOX 251549
Second Line	:
City	:	PLANO
State	:	TX
Zip	:	75025-1500
Country	:	US
Telephone Number	:	214-736-2700
Fax Number	:

Provider Business Practice Location Address
First Line	:	4621 S CENTRAL AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85040-2148
Country	:	US
Telephone Number	:	602-304-1977
Fax Number	:	602-304-1870

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	THOMAS L. WEINBERG
Credential	:
Telephone Number	:	214-736-2700

Provider Enumeration Date	:	09/21/2011
Last Update Date	:	01/04/2021

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