Provider Demographics
NPI:1093864225
Name:WESTERN SKIES DIALYSIS INC
Entity Type:Organization
Organization Name:WESTERN SKIES DIALYSIS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LETARTE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:520-836-5883
Mailing Address - Street 1:1041 N ARIZOLA RD
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85122-6003
Mailing Address - Country:US
Mailing Address - Phone:520-836-5883
Mailing Address - Fax:520-836-2728
Practice Address - Street 1:1041 N ARIZOLA RD
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-6003
Practice Address - Country:US
Practice Address - Phone:520-836-5883
Practice Address - Fax:520-836-2728
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2010-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTC 0576261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1155239Medicaid
AZ032540Medicare ID - Type Unspecified