Provider Demographics
NPI:1093133001
Name:BRADLEY COUNTY DIALYSIS
Entity Type:Organization
Organization Name:BRADLEY COUNTY DIALYSIS
Other - Org Name:RENAL TREATMENT CTRS SOUTHEAST LP
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KENT
Authorized Official - Middle Name:
Authorized Official - Last Name:THIRY
Authorized Official - Suffix:
Authorized Official - Credentials:CHAIRMAN
Authorized Official - Phone:303-876-6000
Mailing Address - Street 1:204 BRAGG ST
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:AR
Mailing Address - Zip Code:71671-2500
Mailing Address - Country:US
Mailing Address - Phone:870-226-7180
Mailing Address - Fax:870-226-2488
Practice Address - Street 1:1423 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-4203
Practice Address - Country:US
Practice Address - Phone:253-382-1752
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-07
Last Update Date:2014-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR04D1050400261QE0700X
AR1194069617261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR200362134Medicaid