Provider Demographics
NPI:1063688844
Name:021808 LLC
Entity Type:Organization
Organization Name:021808 LLC
Other - Org Name:LIBERTY DIALYSIS - COLORADO SPRINGS SOUTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BLANTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-699-9000
Mailing Address - Street 1:2508 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80910-3120
Mailing Address - Country:US
Mailing Address - Phone:719-227-7455
Mailing Address - Fax:719-227-7456
Practice Address - Street 1:2508 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80910-3120
Practice Address - Country:US
Practice Address - Phone:719-227-7455
Practice Address - Fax:719-227-7456
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FRESENIUS MEDICAL CARE HOLDINGS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-01
Last Update Date:2023-10-17
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
CO062564Medicare Oscar/Certification