Provider Demographics
NPI:1497870885
Name:LEESVILLE DIALYSIS CENTER, LLC
Entity Type:Organization
Organization Name:LEESVILLE DIALYSIS CENTER, LLC
Other - Org Name:LEESVILLE DIALYSIS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:J
Authorized Official - Last Name:DIVITO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-699-9000
Mailing Address - Street 1:900 N 5TH ST STE 5
Mailing Address - Street 2:
Mailing Address - City:LEESVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71446-3530
Mailing Address - Country:US
Mailing Address - Phone:337-392-5122
Mailing Address - Fax:337-392-1192
Practice Address - Street 1:900 N 5TH ST STE 5
Practice Address - Street 2:
Practice Address - City:LEESVILLE
Practice Address - State:LA
Practice Address - Zip Code:71446-3530
Practice Address - Country:US
Practice Address - Phone:337-392-5122
Practice Address - Fax:337-392-1192
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2020-11-16
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
LA1193062Medicaid
LA1193062Medicaid