Provider Demographics
NPI:1760803951
Name:GREAT LAKES DIALYSIS WEST LLC
Entity Type:Organization
Organization Name:GREAT LAKES DIALYSIS WEST LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT/MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BONIFACE
Authorized Official - Middle Name:A
Authorized Official - Last Name:TUBIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-914-0121
Mailing Address - Street 1:20755 GREENFIELD RD STE 203
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-5405
Mailing Address - Country:US
Mailing Address - Phone:248-395-2206
Mailing Address - Fax:248-395-0456
Practice Address - Street 1:27150 W 8 MILE RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48033-3590
Practice Address - Country:US
Practice Address - Phone:248-914-0121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-15
Last Update Date:2013-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment