Provider Demographics
NPI:1114158425
Name:PACIFIC DIALYSIS CENTER LLC
Entity Type:Organization
Organization Name:PACIFIC DIALYSIS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:RENE
Authorized Official - Middle Name:O
Authorized Official - Last Name:RANDLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-268-4575
Mailing Address - Street 1:9444 FLORIDA BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70815-1123
Mailing Address - Country:US
Mailing Address - Phone:225-268-4575
Mailing Address - Fax:225-927-7087
Practice Address - Street 1:9444 FLORIDA BLVD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70815-1123
Practice Address - Country:US
Practice Address - Phone:225-268-4575
Practice Address - Fax:225-927-7087
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-04
Last Update Date:2009-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA019120291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory