Provider Demographics
NPI:1679819684
Name:DIALYSIS CLINIC INC
Entity Type:Organization
Organization Name:DIALYSIS CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DONOVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHULTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-327-3061
Mailing Address - Street 1:1500 INDIAN SCHOOL RD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-1646
Mailing Address - Country:US
Mailing Address - Phone:505-243-7376
Mailing Address - Fax:505-724-1528
Practice Address - Street 1:14 EAST CORDOVA AVE
Practice Address - Street 2:
Practice Address - City:CUBA
Practice Address - State:NM
Practice Address - Zip Code:87103
Practice Address - Country:US
Practice Address - Phone:575-289-0090
Practice Address - Fax:575-289-0166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-19
Last Update Date:2023-10-05
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
NM322543Medicare Oscar/Certification