Provider Demographics
NPI:1578879847
Name:DIALYSIS ACCESS CENTER, LLC
Entity Type:Organization
Organization Name:DIALYSIS ACCESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RAJESH
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-762-5570
Mailing Address - Street 1:400 JOHN DEERE RD
Mailing Address - Street 2:BUILDING 2
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6898
Mailing Address - Country:US
Mailing Address - Phone:309-797-0594
Mailing Address - Fax:309-762-5297
Practice Address - Street 1:400 JOHN DEERE RD
Practice Address - Street 2:BUILDING 2
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6898
Practice Address - Country:US
Practice Address - Phone:309-797-0594
Practice Address - Fax:309-762-5297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-25
Last Update Date:2014-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL5611OtherMEDICARE PTAN
IL51756OtherBLUE CROSS BLUE SHIELD OF ILLINOIS
IL=========001Medicaid
IL51756OtherBLUE CROSS BLUE SHIELD OF ILLINOIS