Provider Demographics
NPI:1073060638
Name:LIBERTY DIALYSIS - HAWAII LLC
Entity Type:Organization
Organization Name:LIBERTY DIALYSIS - HAWAII LLC
Other - Org Name:LIBERTY DIALYSIS HAWAII-HAWAII SALT LAKE
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 1:4380 LAWEHANA ST STE 100
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96818-3129
Mailing Address - Country:US
Mailing Address - Phone:808-423-6828
Mailing Address - Fax:808-422-6049
Practice Address - Street 1:4380 LAWEHANA ST STE 100
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96818-3129
Practice Address - Country:US
Practice Address - Phone:808-423-6828
Practice Address - Fax:808-422-6049
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FRESENIUS MEDICAL CARE HOLDINGS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-09-01
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI12-2530OtherPTAN