Provider Demographics
NPI:1821477415
Name:LIBERTY AT HOME DIALYSIS, LLC
Entity Type:Organization
Organization Name:LIBERTY AT HOME DIALYSIS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:SANTELLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-236-5001
Mailing Address - Street 1:5535 RED BIRD CENTER DR
Mailing Address - Street 2:SUITE 150
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75237-1921
Mailing Address - Country:US
Mailing Address - Phone:214-331-1112
Mailing Address - Fax:
Practice Address - Street 1:5535 RED BIRD CENTER DR
Practice Address - Street 2:SUITE 150
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75237-1921
Practice Address - Country:US
Practice Address - Phone:214-331-1112
Practice Address - Fax:214-331-1115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-28
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX017487251E00000X
TX261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
No251E00000XAgenciesHome Health