Provider Demographics
NPI:1174833057
Name:TOOELE MOBILE DIALYSIS LLC
Entity Type:Organization
Organization Name:TOOELE MOBILE DIALYSIS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:HODSON
Authorized Official - Middle Name:
Authorized Official - Last Name:JEAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-867-7464
Mailing Address - Street 1:1298 E 850 N
Mailing Address - Street 2:
Mailing Address - City:TOOELE
Mailing Address - State:UT
Mailing Address - Zip Code:84074-8914
Mailing Address - Country:US
Mailing Address - Phone:801-867-7464
Mailing Address - Fax:801-606-2950
Practice Address - Street 1:1298 E 850 N
Practice Address - Street 2:
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074-8914
Practice Address - Country:US
Practice Address - Phone:801-867-7464
Practice Address - Fax:801-606-2950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-13
Last Update Date:2010-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2010216261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment