Provider Demographics
NPI:1518057918
Name:LIBERTY DIALYSIS - LAFAYETTE, LLC
Entity Type:Organization
Organization Name:LIBERTY DIALYSIS - LAFAYETTE, LLC
Other - Org Name:LIBERTY DIALYSIS - MONTICELLO
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 1:810 S 6TH ST STE I
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:IN
Mailing Address - Zip Code:47960-8201
Mailing Address - Country:US
Mailing Address - Phone:574-583-3576
Mailing Address - Fax:574-583-3896
Practice Address - Street 1:810 S 6TH ST STE I
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:IN
Practice Address - Zip Code:47960-8201
Practice Address - Country:US
Practice Address - Phone:574-583-3576
Practice Address - Fax:574-583-3896
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FRESENIUS MEDICAL CARE HOLDINGS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-13
Last Update Date:2021-08-19
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
IN152602Medicare Oscar/Certification