MEDICARE: EUMANA HOME 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	17448	TX

General Provider Information

NPI Number	:	1881701480
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EUMANA HOME DIALYSIS, INC.

Provider Business Mailing Address
First Line	:	1313 LA CONCHA LN
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77054-1809
Country	:	US
Telephone Number	:	713-668-2744
Fax Number	:	713-795-5959

Provider Business Practice Location Address
First Line	:	1313 LA CONCHA LN
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77054-1809
Country	:	US
Telephone Number	:	713-668-2744
Fax Number	:	713-795-5959

Authorized Official
Title or Position	:	PHARMACIST
Name	:	UCHEGBULEM ALOYSIUS EZE
Credential	:	PHARM.D
Telephone Number	:	713-668-2744

Provider Enumeration Date	:	08/23/2006
Last Update Date	:	08/22/2020

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