Provider Demographics
NPI:1659767150
Name:D'IBERVILLE HOME PROGRAM, LLC
Entity Type:Organization
Organization Name:D'IBERVILLE HOME PROGRAM, LLC
Other - Org Name:D'IBERVILLE HOME PROGRAM
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 1:14215 COOK RD
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39532-9719
Mailing Address - Country:US
Mailing Address - Phone:228-872-0516
Mailing Address - Fax:228-872-8322
Practice Address - Street 1:14215 COOK RD
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39532-9719
Practice Address - Country:US
Practice Address - Phone:228-872-0516
Practice Address - Fax:228-872-8322
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FRESENIUS MEDICAL CARE HOLDINGS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-04-10
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment