Provider Demographics
NPI:1639115785
Name:BOISE DIALYSIS LLC
Entity Type:Organization
Organization Name:BOISE DIALYSIS LLC
Other - Org Name:BOISE DIALYSIS, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BLANTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-699-9000
Mailing Address - Street 1:3525 E LOUISE DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-6303
Mailing Address - Country:US
Mailing Address - Phone:208-846-9815
Mailing Address - Fax:208-884-2032
Practice Address - Street 1:3525 E LOUISE DR
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6303
Practice Address - Country:US
Practice Address - Phone:208-846-9815
Practice Address - Fax:208-884-2032
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FRESENIUS MEDICAL CARE HOLDINGS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-20
Last Update Date:2023-10-17
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
ID000010155375OtherREGENCY BLUE SHIED OF IDA
ID04846OtherBLUE CROSS OF IDAHO
ID132512Medicare Oscar/Certification