Provider Demographics
NPI:1073846655
Name:LIBERTY DIALYSIS-JORDAN LANDING LLC
Entity Type:Organization
Organization Name:LIBERTY DIALYSIS-JORDAN LANDING LLC
Other - Org Name:LIBERTY DIALYSIS - WEST JORDAN
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 1:3823 W 9000 S STE D
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-5604
Mailing Address - Country:US
Mailing Address - Phone:801-280-4600
Mailing Address - Fax:801-280-0444
Practice Address - Street 1:3823 W 9000 S STE D
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-5604
Practice Address - Country:US
Practice Address - Phone:801-280-4600
Practice Address - Fax:801-280-0444
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FRESENIUS MEDICAL CARE HOLDINGS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-09-14
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
UT46-2545OtherPTAN
UT462545Medicare Oscar/Certification