Provider Demographics
NPI:1699037028
Name:HOME DIALYSIS SPECIALTY CENTER LLC
Entity Type:Organization
Organization Name:HOME DIALYSIS SPECIALTY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MS
Authorized Official - First Name:FATEN
Authorized Official - Middle Name:
Authorized Official - Last Name:AYYOUB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-642-5038
Mailing Address - Street 1:30100 TELEGRAPH RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BINGHAM FARMS
Mailing Address - State:MI
Mailing Address - Zip Code:48025-4516
Mailing Address - Country:US
Mailing Address - Phone:248-723-0219
Mailing Address - Fax:
Practice Address - Street 1:29001 HARPER AVE
Practice Address - Street 2:
Practice Address - City:ST CLR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081-2711
Practice Address - Country:US
Practice Address - Phone:248-642-5038
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-12
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MID74250261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI232691Medicare Oscar/Certification