MEDICARE: FORT LAUDERDALE RENAL DIALYSIS 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

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	:	1801160809
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FORT LAUDERDALE RENAL DIALYSIS LLC

Provider Business Mailing Address
First Line	:	6264 N FEDERAL HWY
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33308-1904
Country	:	US
Telephone Number	:	954-776-3791
Fax Number	:	954-771-7527

Provider Business Practice Location Address
First Line	:	6264 N FEDERAL HWY
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33308-1904
Country	:	US
Telephone Number	:	954-776-3791
Fax Number	:	954-771-7527

Authorized Official
Title or Position	:	SR. VP OF CLINICAL & REGULATORY
Name	:	SHARI K COUSINS
Credential	:
Telephone Number	:	978-922-3080

Provider Enumeration Date	:	03/08/2012
Last Update Date	:	03/16/2020

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