Provider Demographics
NPI:1437246063
Name:COMMUNITY DIALYSIS CENTER
Entity Type:Organization
Organization Name:COMMUNITY DIALYSIS CENTER
Other - Org Name:CENTER FOR DIALYSIS CARE, MENTOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRES AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:P
Authorized Official - Last Name:WISH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-295-7003
Mailing Address - Street 1:18720 CHAGRIN BLVD
Mailing Address - Street 2:
Mailing Address - City:SHAKER HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44122-4855
Mailing Address - Country:US
Mailing Address - Phone:216-295-7003
Mailing Address - Fax:216-295-7014
Practice Address - Street 1:8900 TYLER BLVD
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-2185
Practice Address - Country:US
Practice Address - Phone:440-951-3602
Practice Address - Fax:440-255-7581
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0639DC261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0431803Medicaid
362505Medicare ID - Type Unspecified