Provider Demographics
NPI:1619274735
Name:WESTSIDE DIALYSIS UNIT LLC
Entity Type:Organization
Organization Name:WESTSIDE DIALYSIS UNIT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MOSES
Authorized Official - Middle Name:C
Authorized Official - Last Name:EJIOFOR
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:501-603-9277
Mailing Address - Street 1:1515 KANIS PARK DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-4569
Mailing Address - Country:US
Mailing Address - Phone:501-603-9277
Mailing Address - Fax:501-603-9277
Practice Address - Street 1:1515 KANIS PARK DR
Practice Address - Street 2:SUITE A
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-4569
Practice Address - Country:US
Practice Address - Phone:501-603-9277
Practice Address - Fax:501-603-9877
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR211230134Medicaid
AR042591Medicare PIN