Provider Demographics
NPI:1124190483
Name:FAIRFIELD KIDNEY CENTER LLC
Entity Type:Organization
Organization Name:FAIRFIELD KIDNEY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF NURSING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SARA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:BRADY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-371-7878
Mailing Address - Street 1:618 PLEASANTVILLE RD
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:OH
Mailing Address - Zip Code:43130-3312
Mailing Address - Country:US
Mailing Address - Phone:740-687-6480
Mailing Address - Fax:740-687-6490
Practice Address - Street 1:618 PLEASANTVILLE RD
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:OH
Practice Address - Zip Code:43130-3312
Practice Address - Country:US
Practice Address - Phone:740-687-6480
Practice Address - Fax:740-687-6490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2023-01-10
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
OH2749440Medicaid
OH362693Medicare Oscar/Certification