MEDICARE: HOME DIALYSIS OF LINCOLN, 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		NE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1629252770
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOME DIALYSIS OF LINCOLN, LLC

Provider Business Mailing Address
First Line	:	7910 O ST
Second Line	:
City	:	LINCOLN
State	:	NE
Zip	:	68510-2500
Country	:	US
Telephone Number	:	402-489-5339
Fax Number	:	402-489-7366

Provider Business Practice Location Address
First Line	:	5355 S 16TH ST
Second Line	:
City	:	LINCOLN
State	:	NE
Zip	:	68512-1277
Country	:	US
Telephone Number	:	402-489-5339
Fax Number	:	402-489-7366

Authorized Official
Title or Position	:	C.F.O.
Name	:	MR. KAREL S. SYSEL
Credential	:
Telephone Number	:	402-489-5339

Provider Enumeration Date	:	12/26/2007
Last Update Date	:	05/10/2011

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