Provider Demographics
NPI:1376053892
Name:LAWTON DIALYSIS CENTER-EAST LLC
Entity Type:Organization
Organization Name:LAWTON DIALYSIS CENTER-EAST LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BALI
Authorized Official - Middle Name:REDDY
Authorized Official - Last Name:SODAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-536-5273
Mailing Address - Street 1:4516 SE LEE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73501-6558
Mailing Address - Country:US
Mailing Address - Phone:580-351-1430
Mailing Address - Fax:580-351-9980
Practice Address - Street 1:4516 SE LEE BLVD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73501-6558
Practice Address - Country:US
Practice Address - Phone:580-351-1430
Practice Address - Fax:580-351-9980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-11
Last Update Date:2023-01-12
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
OK200753010AMedicaid