Provider Demographics
NPI:1760810378
Name:LEWISVILLE LD, LLC
Entity Type:Organization
Organization Name:LEWISVILLE LD, LLC
Other - Org Name:LIBERTY DIALYSIS OF SOUTH LEWISVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SVP AND TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:R
Authorized Official - Last Name:FAWCETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-699-9000
Mailing Address - Street 1:101 E SW PKWY
Mailing Address - Street 2:STE 110
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75067-8791
Mailing Address - Country:US
Mailing Address - Phone:469-549-7424
Mailing Address - Fax:469-549-4740
Practice Address - Street 1:101 E SW PKWY
Practice Address - Street 2:STE 110
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75067-8791
Practice Address - Country:US
Practice Address - Phone:469-549-7424
Practice Address - Fax:469-549-4740
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FRESENIUS MEDICAL CARE HOLDINGS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-10-16
Last Update Date:2016-12-20
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
TX672795Medicare Oscar/Certification