Provider Demographics
NPI:1003227075
Name:DESOTO REGIONAL DIALYSIS CENTER LLC
Entity Type:Organization
Organization Name:DESOTO REGIONAL DIALYSIS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF NURSING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SARA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:BRADY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-371-7878
Mailing Address - Street 1:2651 BOLTON BOONE DR
Mailing Address - Street 2:BUILDING B
Mailing Address - City:DESOTO
Mailing Address - State:TX
Mailing Address - Zip Code:75115-2011
Mailing Address - Country:US
Mailing Address - Phone:972-780-5991
Mailing Address - Fax:972-780-5992
Practice Address - Street 1:2651 BOLTON BOONE DR
Practice Address - Street 2:BUILDING B
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-2011
Practice Address - Country:US
Practice Address - Phone:972-780-5991
Practice Address - Fax:972-780-5992
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-13
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX364692901Medicaid
TX672791Medicare Oscar/Certification