Provider Demographics
NPI:1083950984
Name:END STAGE RENAL DISEASE HOME CARE PROVIDER AGENCY
Entity Type:Organization
Organization Name:END STAGE RENAL DISEASE HOME CARE PROVIDER AGENCY
Other - Org Name:NONE
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/SUPPLY
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:HENRY
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:414-759-8587
Mailing Address - Street 1:PO BOX 6911
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-0632
Mailing Address - Country:US
Mailing Address - Phone:414-759-8587
Mailing Address - Fax:
Practice Address - Street 1:22356 W LASSO LN
Practice Address - Street 2:
Practice Address - City:BUCKEYE
Practice Address - State:AZ
Practice Address - Zip Code:85326-5979
Practice Address - Country:US
Practice Address - Phone:623-210-2710
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-20
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BD1200XSuppliersDurable Medical Equipment & Medical SuppliesDialysis Equipment & Supplies