Provider Demographics
NPI:1407001613
Name:PERMIAN NEPHROLOGY ASSOCIATES PA
Entity Type:Organization
Organization Name:PERMIAN NEPHROLOGY ASSOCIATES PA
Other - Org Name:DESERT MILAGRO DIALYSIS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:D
Authorized Official - Last Name:OLIVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:432-522-2304
Mailing Address - Street 1:230 N WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-5424
Mailing Address - Country:US
Mailing Address - Phone:432-580-8181
Mailing Address - Fax:432-580-4259
Practice Address - Street 1:230 N WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-5424
Practice Address - Country:US
Practice Address - Phone:432-580-8181
Practice Address - Fax:432-580-4259
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-02
Last Update Date:2009-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment