Provider Demographics
NPI:1427534072
Name:LEGACY DIALYSIS OF FAIRFAX LLC
Entity Type:Organization
Organization Name:LEGACY DIALYSIS OF FAIRFAX LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MYRLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:BARRERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-778-8277
Mailing Address - Street 1:100 E SAMPLE RD STE 210
Mailing Address - Street 2:
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33064-3554
Mailing Address - Country:US
Mailing Address - Phone:954-781-7741
Mailing Address - Fax:888-349-8679
Practice Address - Street 1:10565 FAIRFAX BLVD STE 205
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-3104
Practice Address - Country:US
Practice Address - Phone:571-340-3221
Practice Address - Fax:571-340-3404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-17
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment