Provider Demographics
NPI:1508037011
Name:DIALYSIS ACCESS CENTER LLC
Entity Type:Organization
Organization Name:DIALYSIS ACCESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:MS
Authorized Official - First Name:LYSA
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-388-2065
Mailing Address - Street 1:357 AVE HOSTOS
Mailing Address - Street 2:OFFICE PARK II SUITE 203
Mailing Address - City:MAYAGUEZ
Mailing Address - State:PR
Mailing Address - Zip Code:00680-1507
Mailing Address - Country:US
Mailing Address - Phone:847-388-2065
Mailing Address - Fax:866-720-9740
Practice Address - Street 1:357 AVE HOSTOS
Practice Address - Street 2:OFFICE PARK II SUITE 203
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00680-1507
Practice Address - Country:US
Practice Address - Phone:847-388-2065
Practice Address - Fax:866-720-9740
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-13
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty