Provider Demographics
NPI:1437426897
Name:TERRELL DIALYSIS CENTER, LLC
Entity Type:Organization
Organization Name:TERRELL DIALYSIS CENTER, LLC
Other - Org Name:FMC DIALYSIS SERVICES GRAPEVINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:R
Authorized Official - Last Name:FAWCETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-699-9000
Mailing Address - Street 1:1601 HART CT
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-9707
Mailing Address - Country:US
Mailing Address - Phone:817-329-1866
Mailing Address - Fax:817-329-6079
Practice Address - Street 1:1601 HART CT
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-9707
Practice Address - Country:US
Practice Address - Phone:817-329-1866
Practice Address - Fax:817-329-6079
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FRESENIUS MEDICAL CARE HOLDINGS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-11-29
Last Update Date:2011-11-29
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
452832Medicare Oscar/Certification