Provider Demographics
NPI:1598711137
Name:CLARK COUNTY DIALYSIS FACILITY, INC.
Entity Type:Organization
Organization Name:CLARK COUNTY DIALYSIS FACILITY, INC.
Other - Org Name:CCDF
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:S
Authorized Official - Last Name:SPIERS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:937-328-8933
Mailing Address - Street 1:247 S BURNETT RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45505-2639
Mailing Address - Country:US
Mailing Address - Phone:937-328-8921
Mailing Address - Fax:937-328-8784
Practice Address - Street 1:247 S BURNETT RD
Practice Address - Street 2:SUITE 110
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45505-2639
Practice Address - Country:US
Practice Address - Phone:937-328-8921
Practice Address - Fax:937-328-8784
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH192261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0545066Medicaid
OH0545066Medicaid