Provider Demographics
NPI:1275526113
Name:PERITONEAL DIALYSIS SUPPLY, LLC
Entity Type:Organization
Organization Name:PERITONEAL DIALYSIS SUPPLY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JUNE
Authorized Official - Middle Name:A
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-738-5255
Mailing Address - Street 1:1964 BAYSHORE BLVD SUITE C
Mailing Address - Street 2:
Mailing Address - City:DUNEDIN
Mailing Address - State:FL
Mailing Address - Zip Code:34698-2576
Mailing Address - Country:US
Mailing Address - Phone:727-738-5255
Mailing Address - Fax:727-733-0431
Practice Address - Street 1:1964 BAYSHORE BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:DUNEDIN
Practice Address - State:FL
Practice Address - Zip Code:34698-2576
Practice Address - Country:US
Practice Address - Phone:727-738-5255
Practice Address - Fax:727-733-0431
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-25
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL332BD1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BD1200XSuppliersDurable Medical Equipment & Medical SuppliesDialysis Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
4790620001Medicare NSC