Provider Demographics
NPI:1073625976
Name:PACIFIC NORTHWEST RENAL SERVICES, L.L.C.
Entity Type:Organization
Organization Name:PACIFIC NORTHWEST RENAL SERVICES, L.L.C.
Other - Org Name:PNRS-NORTH COAST DIALYSIS CLINIC
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 1:632 MARINE DR
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103-4249
Mailing Address - Country:US
Mailing Address - Phone:971-606-6015
Mailing Address - Fax:503-325-4114
Practice Address - Street 1:632 MARINE DR
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-4249
Practice Address - Country:US
Practice Address - Phone:971-606-6015
Practice Address - Fax:503-325-4114
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FRESENIUS MEDICAL CARE HOLDINGS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-31
Last Update Date:2023-10-16
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
OR382535Medicare Oscar/Certification