Provider Demographics
NPI:1629372628
Name:LDBH, LLC
Entity Type:Organization
Organization Name:LDBH, LLC
Other - Org Name:LIBERTY DIALYSIS AT LAKELAND WATERVLIET
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:B
Authorized Official - Last Name:PARDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-236-5001
Mailing Address - Street 1:7650 SE 27TH ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MERCER ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98040-3060
Mailing Address - Country:US
Mailing Address - Phone:206-588-8621
Mailing Address - Fax:206-588-8661
Practice Address - Street 1:400 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:WATERVLIET
Practice Address - State:MI
Practice Address - Zip Code:49098-9225
Practice Address - Country:US
Practice Address - Phone:269-684-0116
Practice Address - Fax:269-684-0271
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-05
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment