Provider Demographics
NPI:1740558618
Name:BROCKTON DIALYSIS CENTER LLC
Entity Type:Organization
Organization Name:BROCKTON DIALYSIS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF NURSING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SARA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:BRADY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-371-7878
Mailing Address - Street 1:375 WESTGATE DR
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-1818
Mailing Address - Country:US
Mailing Address - Phone:508-586-2791
Mailing Address - Fax:508-583-6986
Practice Address - Street 1:375 WESTGATE DR
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-1818
Practice Address - Country:US
Practice Address - Phone:508-586-2791
Practice Address - Fax:508-583-6986
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-07
Last Update Date:2023-01-10
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
MA110091941AMedicaid
MA222505Medicare Oscar/Certification