Provider Demographics
NPI:1124001169
Name:NORTH TEXAS DIALYSIS CLINIC, LLC
Entity Type:Organization
Organization Name:NORTH TEXAS DIALYSIS CLINIC, LLC
Other - Org Name:NORTH TEXAS DIALYSIS CLINIC, LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:CORPANY
Authorized Official - Suffix:
Authorized Official - Credentials:BS, PA, CNT
Authorized Official - Phone:940-566-2701
Mailing Address - Street 1:4309 MESA DR
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76207-3457
Mailing Address - Country:US
Mailing Address - Phone:940-566-2701
Mailing Address - Fax:940-382-2558
Practice Address - Street 1:1110 E CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:TX
Practice Address - Zip Code:76240-4206
Practice Address - Country:US
Practice Address - Phone:940-612-5555
Practice Address - Fax:940-612-0735
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX007258174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX007258OtherSTATE LICENSE-ESRD FAC
TX007258OtherSTATE LICENSE-ESRD FAC