Provider Demographics
NPI:1467507103
Name:LIBERTY DIALYSIS - HAWAII LLC
Entity Type:Organization
Organization Name:LIBERTY DIALYSIS - HAWAII LLC
Other - Org Name:LIBERTY DIALYSIS HAWAII - MOLOKAI DIALYSIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BLANTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-699-9000
Mailing Address - Street 1:28 KAMOI ST
Mailing Address - Street 2:STE 400
Mailing Address - City:KAUNAKAKAI
Mailing Address - State:HI
Mailing Address - Zip Code:96748-0000
Mailing Address - Country:US
Mailing Address - Phone:808-553-8088
Mailing Address - Fax:808-553-3210
Practice Address - Street 1:28 KAMOI ST
Practice Address - Street 2:STE 400
Practice Address - City:KAUNAKAKAI
Practice Address - State:HI
Practice Address - Zip Code:96748-0000
Practice Address - Country:US
Practice Address - Phone:808-553-8088
Practice Address - Fax:808-553-3210
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FRESENIUS MEDICAL CARE HOLDINGS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-24
Last Update Date:2023-10-17
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
HI582503Medicaid
HI122517Medicare Oscar/Certification