Provider Demographics
NPI:1255509170
Name:LIBERTY DIALYSIS - CASTLE ROCK LLC
Entity Type:Organization
Organization Name:LIBERTY DIALYSIS - CASTLE ROCK LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:B
Authorized Official - Last Name:PARDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-816-6506
Mailing Address - Street 1:7650 SE 27TH ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MERCER ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98040-3060
Mailing Address - Country:US
Mailing Address - Phone:206-236-5001
Mailing Address - Fax:
Practice Address - Street 1:4352 TRAIL BOSS DR
Practice Address - Street 2:
Practice Address - City:CASTLE ROCK
Practice Address - State:CO
Practice Address - Zip Code:80104-7512
Practice Address - Country:US
Practice Address - Phone:206-236-5001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-13
Last Update Date:2011-04-06
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
CO062565Medicare Oscar/Certification