Provider Demographics
NPI:1073902722
Name:IHOME DIALYSIS LLC
Entity Type:Organization
Organization Name:IHOME DIALYSIS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP/CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:M
Authorized Official - Last Name:ASA
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:503-519-2672
Mailing Address - Street 1:12045 SE PARDEE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97266-3220
Mailing Address - Country:US
Mailing Address - Phone:503-519-2672
Mailing Address - Fax:503-761-0320
Practice Address - Street 1:12045 SE PARDEE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97266-3220
Practice Address - Country:US
Practice Address - Phone:503-519-2672
Practice Address - Fax:503-761-0320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-19
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1899501978261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment