Provider Demographics
NPI:1659745149
Name:GRAND DIALYSIS SERVICES LLC
Entity Type:Organization
Organization Name:GRAND DIALYSIS SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:CARRASCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-962-9640
Mailing Address - Street 1:7765 JOHNSON ST
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33024-6856
Mailing Address - Country:US
Mailing Address - Phone:954-962-9640
Mailing Address - Fax:
Practice Address - Street 1:500 N. HIATUS ROAD
Practice Address - Street 2:SUITE 105
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33026
Practice Address - Country:US
Practice Address - Phone:954-962-9640
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-20
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLL15000170783261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment