Provider Demographics
NPI:1558518423
Name:WEST BROOMFIELD DIALYSIS LLC
Entity Type:Organization
Organization Name:WEST BROOMFIELD DIALYSIS LLC
Other - Org Name:WEST BLOOMFIELD DIALYSIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:HILGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-382-1919
Mailing Address - Street 1:5200 VIRGINIA WAY
Mailing Address - Street 2:STE 400 L&C
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-7569
Mailing Address - Country:US
Mailing Address - Phone:615-341-6480
Mailing Address - Fax:866-381-9878
Practice Address - Street 1:6010 W MAPLE RD
Practice Address - Street 2:STE 215
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-4406
Practice Address - Country:US
Practice Address - Phone:248-539-1025
Practice Address - Fax:248-539-2986
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-22
Last Update Date:2010-12-06
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
232661Medicare Oscar/Certification