Provider Demographics
NPI:1609044569
Name:LIBERTY DIALYSIS-NORTHWEST RENO LLC
Entity Type:Organization
Organization Name:LIBERTY DIALYSIS-NORTHWEST RENO LLC
Other - Org Name:LIBERTY DIALYSIS-NORTHWEST RENO, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:FAWCETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-699-9000
Mailing Address - Street 1:6144 MAE ANNE AVE
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89523-4721
Mailing Address - Country:US
Mailing Address - Phone:775-747-1100
Mailing Address - Fax:775-747-1115
Practice Address - Street 1:6144 MAE ANNE AVE
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89523-4721
Practice Address - Country:US
Practice Address - Phone:775-747-1100
Practice Address - Fax:775-747-1115
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FRESENIUS MEDICAL CARE HOLDINGS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-13
Last Update Date:2024-01-23
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
NV292541Medicare Oscar/Certification