Provider Demographics
NPI:1306203609
Name:MAIN STREET DIALYSIS CENTER LLC
Entity Type:Organization
Organization Name:MAIN STREET DIALYSIS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:IHEANYICHUKWU
Authorized Official - Middle Name:
Authorized Official - Last Name:AJA-ONU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-771-7112
Mailing Address - Street 1:PO BOX 037216
Mailing Address - Street 2:
Mailing Address - City:ELMONT
Mailing Address - State:NY
Mailing Address - Zip Code:11003-7216
Mailing Address - Country:US
Mailing Address - Phone:516-771-7112
Mailing Address - Fax:
Practice Address - Street 1:3 N MAIN ST
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:NY
Practice Address - Zip Code:11520-2218
Practice Address - Country:US
Practice Address - Phone:516-825-2076
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-19
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY052083-B261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment