MEDICARE: MISSION DIALYSIS SERVICES 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	110282	TX

General Provider Information

NPI Number	:	1932651155
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MISSION DIALYSIS SERVICES LLC

Provider Business Mailing Address
First Line	:	19559 NE 10TH AVE
Second Line	:
City	:	NORTH MIAMI BEACH
State	:	FL
Zip	:	33179-3501
Country	:	US
Telephone Number	:	305-651-3261
Fax Number	:

Provider Business Practice Location Address
First Line	:	3305 UNICORN LAKE BLVD
Second Line	:
City	:	DENTON
State	:	TX
Zip	:	76210-0102
Country	:	US
Telephone Number	:	940-387-4592
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MISS GARY J BOOTH
Credential	:
Telephone Number	:	305-651-3261

Provider Enumeration Date	:	11/04/2016
Last Update Date	:	11/04/2016

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