Provider Demographics
NPI:1104019447
Name:JOHNSON DIALYSIS CENTER LLC
Entity Type:Organization
Organization Name:JOHNSON DIALYSIS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:CARRASCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-962-9640
Mailing Address - Street 1:7769 JOHNSON ST
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33024-6856
Mailing Address - Country:US
Mailing Address - Phone:954-962-9640
Mailing Address - Fax:954-962-9641
Practice Address - Street 1:7769 JOHNSON ST
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33024-6856
Practice Address - Country:US
Practice Address - Phone:954-962-9640
Practice Address - Fax:954-962-9641
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-21
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000791100Medicaid
FL000791100Medicaid