Provider Demographics
NPI:1184014912
Name:FLORIDA DIALYSIS CENTER OF HAINES CITY LLC
Entity Type:Organization
Organization Name:FLORIDA DIALYSIS CENTER OF HAINES CITY 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 1:2340 NORTH BOULEVARD WEST
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33837-8924
Mailing Address - Country:US
Mailing Address - Phone:863-353-6886
Mailing Address - Fax:863-547-9527
Practice Address - Street 1:2340 NORTH BOULEVARD WEST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33837-8924
Practice Address - Country:US
Practice Address - Phone:863-353-6886
Practice Address - Fax:863-547-9527
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-02
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
FL015769300Medicaid
FL015769300Medicaid