Provider Demographics
NPI:1285213850
Name:LIVARY DIALYSIS LLC
Entity Type:Organization
Organization Name:LIVARY DIALYSIS LLC
Other - Org Name:GRANTS LAKE DIALYSIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF ACCOUNTING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:WINSTEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-733-4501
Mailing Address - Street 1:5200 VIRGINIA WAY
Mailing Address - Street 2:L&C DEPT
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-7569
Mailing Address - Country:US
Mailing Address - Phone:615-320-4224
Mailing Address - Fax:800-293-4707
Practice Address - Street 1:16035 LEXINGTON BLVD
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77479-2316
Practice Address - Country:US
Practice Address - Phone:832-783-9090
Practice Address - Fax:888-835-3621
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DAVITA INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-04-02
Last Update Date:2023-06-13
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
TX432295001Medicaid