Provider Demographics
NPI:1669512042
Name:DIALYSIS ACCESS OF MINNESOTA, L.L.C.
Entity Type:Organization
Organization Name:DIALYSIS ACCESS OF MINNESOTA, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:763-561-5349
Mailing Address - Street 1:6200 SHINGLE CREEK PKWY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55430-2128
Mailing Address - Country:US
Mailing Address - Phone:763-561-5349
Mailing Address - Fax:763-561-6280
Practice Address - Street 1:600 COUNTY ROAD D W
Practice Address - Street 2:
Practice Address - City:NEW BRIGHTON
Practice Address - State:MN
Practice Address - Zip Code:55112-3519
Practice Address - Country:US
Practice Address - Phone:763-561-5349
Practice Address - Fax:763-561-6280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical