Provider Demographics
NPI:1619120698
Name:NORTHWEST JACKSONVILLE DIALYSIS CENTER LLC
Entity Type:Organization
Organization Name:NORTHWEST JACKSONVILLE DIALYSIS CENTER LLC
Other - Org Name:ARA NORTH JACKSONVILLE
Other - Org Type:Doing Business As
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 1:1725 OAKHURST AVENUE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32208-3282
Mailing Address - Country:US
Mailing Address - Phone:904-766-2279
Mailing Address - Fax:904-924-7568
Practice Address - Street 1:1725 OAKHURST AVENUE
Practice Address - Street 2:SUITE 100
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32208-3282
Practice Address - Country:US
Practice Address - Phone:904-766-2279
Practice Address - Fax:904-924-7568
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-04
Last Update Date:2023-01-11
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
FL000987500Medicaid
FL102877Medicare Oscar/Certification