Provider Demographics
NPI:1588017784
Name:LAKE GRAY DIALYSIS CENTER LLC
Entity type:Organization
Organization Name:LAKE GRAY DIALYSIS CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF NURSING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SARA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:BRADY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-371-7878
Mailing Address - Street 1:6196 LAKE GRAY BLVD
Mailing Address - Street 2:SUITE 112
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32244-7503
Mailing Address - Country:US
Mailing Address - Phone:904-772-0933
Mailing Address - Fax:904-772-0934
Practice Address - Street 1:6196 LAKE GRAY BLVD
Practice Address - Street 2:SUITE 112
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32244-7503
Practice Address - Country:US
Practice Address - Phone:904-772-0933
Practice Address - Fax:904-772-0934
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-22
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment