Provider Demographics
NPI:1043488695
Name:FRESENIUS MEDICAL CARE COMPREHENSIVE CKD SERVICES INC
Entity Type:Organization
Organization Name:FRESENIUS MEDICAL CARE COMPREHENSIVE CKD SERVICES INC
Other - Org Name:CKD SERVICES OF PT. ST. LUCIE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT, TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:FAWCETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-699-2668
Mailing Address - Street 1:920 WINTER ST
Mailing Address - Street 2:FMCNA CKD SERVICES 3W-16
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02451-1521
Mailing Address - Country:US
Mailing Address - Phone:781-699-4160
Mailing Address - Fax:781-699-4046
Practice Address - Street 1:1680 SE LYNGATE DR
Practice Address - Street 2:STE. 101 CKD SERVICES OF PT. ST. LUCIE
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-4300
Practice Address - Country:US
Practice Address - Phone:772-335-2407
Practice Address - Fax:772-335-8509
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FRESENIUS MEDICAL CARE HOLDINGS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-18
Last Update Date:2008-10-21
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
FLAO192Medicare UPIN