Provider Demographics
NPI:1518973932
Name:SOUTHWEST KIDNEY DIALYSIS, LLC
Entity Type:Organization
Organization Name:SOUTHWEST KIDNEY DIALYSIS, LLC
Other - Org Name:SOUTHWEST KIDNEY DIALYSIS - ESTRELLA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHEIF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:R
Authorized Official - Last Name:MAUVAIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-610-6110
Mailing Address - Street 1:2149 E WARNER RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85284-3494
Mailing Address - Country:US
Mailing Address - Phone:623-247-0808
Mailing Address - Fax:623-247-9235
Practice Address - Street 1:8410 W THOMAS ROAD
Practice Address - Street 2:BUILDING 1, SUITE 100
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85037-3494
Practice Address - Country:US
Practice Address - Phone:480-610-6118
Practice Address - Fax:480-610-6195
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ032612OtherMEDICARE