Provider Demographics
NPI:1316009913
Name:TEXARKANA KIDNEY DISEASE & HYPERTENSION CENTER, INC.
Entity Type:Organization
Organization Name:TEXARKANA KIDNEY DISEASE & HYPERTENSION CENTER, INC.
Other - Org Name:LEWISVILLE DIALYSIS
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:D.
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:BLANKENSHIP
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:870-773-1111
Mailing Address - Street 1:422 BEECH ST
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:AR
Mailing Address - Zip Code:71854-5310
Mailing Address - Country:US
Mailing Address - Phone:870-773-1111
Mailing Address - Fax:870-772-7692
Practice Address - Street 1:120 11TH STREET
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:AR
Practice Address - Zip Code:71845
Practice Address - Country:US
Practice Address - Phone:870-921-4111
Practice Address - Fax:870-772-7692
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR042551Medicare ID - Type UnspecifiedESRD FACILITY