Provider Demographics
NPI:1083670988
Name:SOUTHEASTERN RENAL DIALYSIS L.C.
Entity Type:Organization
Organization Name:SOUTHEASTERN RENAL DIALYSIS L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:LIECHTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:319-385-6728
Mailing Address - Street 1:507 S WHITE ST
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:IA
Mailing Address - Zip Code:52641-2625
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1419 MORGAN ST
Practice Address - Street 2:
Practice Address - City:KEOKUK
Practice Address - State:IA
Practice Address - Zip Code:52632-4027
Practice Address - Country:US
Practice Address - Phone:319-524-2105
Practice Address - Fax:319-524-2188
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHEASTERN RENAL DIALYSIS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-04-21
Last Update Date:2012-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0625178Medicaid
IA162517Medicare Oscar/Certification