Provider Demographics
NPI:1639378474
Name:NRA FREDERICKTOWN MISSOURI LLC
Entity Type:Organization
Organization Name:NRA FREDERICKTOWN MISSOURI LLC
Other - Org Name:FREDERICKTOWN DIALYSIS CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:R
Authorized Official - Last Name:FAWCETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-699-9000
Mailing Address - Street 1:105 ARMORY STREET
Mailing Address - Street 2:
Mailing Address - City:FREDERICKTOWN
Mailing Address - State:MO
Mailing Address - Zip Code:63645-1340
Mailing Address - Country:US
Mailing Address - Phone:573-783-2089
Mailing Address - Fax:573-783-7206
Practice Address - Street 1:105 ARMORY STREET
Practice Address - Street 2:
Practice Address - City:FREDERICKTOWN
Practice Address - State:MO
Practice Address - Zip Code:63645-1340
Practice Address - Country:US
Practice Address - Phone:573-783-2089
Practice Address - Fax:573-783-7206
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FRESENIUS MEDICAL CARE HOLDINGS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-07-12
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MONOT APPLICABLE261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO26D1071779OtherCLIA CERT. OF WAIVER
MO504928904Medicaid
MO26D1071779OtherCLIA CERT. OF WAIVER