Provider Demographics
NPI:1336301860
Name:MOUNTAIN WEST DIALYSIS SERVICES LLC
Entity Type:Organization
Organization Name:MOUNTAIN WEST DIALYSIS SERVICES LLC
Other - Org Name:LONGMONT DIALYSIS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF ACCOUNTING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:K
Authorized Official - Last Name:HILGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-733-4500
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:615-320-4521
Mailing Address - Fax:866-594-2894
Practice Address - Street 1:1715 IRON HORSE DR
Practice Address - Street 2:STE 170
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-9617
Practice Address - Country:US
Practice Address - Phone:303-485-4084
Practice Address - Fax:303-485-4081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-26
Last Update Date:2013-12-19
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
CO11485884Medicaid
CO11485884Medicaid