Provider Demographics
NPI:1720011109
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 1:757 UNION ST W
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32202-4765
Mailing Address - Country:US
Mailing Address - Phone:904-354-0409
Mailing Address - Fax:904-354-0416
Practice Address - Street 1:11705 SAN JOSE BLVD STE 100
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-1628
Practice Address - Country:US
Practice Address - Phone:904-296-6362
Practice Address - Fax:904-296-6473
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
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
FL2103478-00Medicaid
FL102649Medicare Oscar/Certification