Provider Demographics
NPI:1104378397
Name:CLOUGH DIALYSIS LLC
Entity Type:Organization
Organization Name:CLOUGH DIALYSIS LLC
Other - Org Name:PHYSICIANS DIALYSIS FRISCO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:J
Authorized Official - Last Name:BOOTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-651-3261
Mailing Address - Street 1:19559 NE 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33179-3501
Mailing Address - Country:US
Mailing Address - Phone:305-651-3261
Mailing Address - Fax:
Practice Address - Street 1:6116 SPORTS VILLAGE RD
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75033-3584
Practice Address - Country:US
Practice Address - Phone:469-362-5763
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-04
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment