Provider Demographics
NPI:1841200573
Name:PACIFIC NORTHWEST RENAL SERVICES, L.L.C.
Entity Type:Organization
Organization Name:PACIFIC NORTHWEST RENAL SERVICES, L.L.C.
Other - Org Name:PNRS BEAVERTON DIALYSIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:J
Authorized Official - Last Name:DIVITO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-699-9000
Mailing Address - Street 1:2715 SW 153RD DR
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97003-5106
Mailing Address - Country:US
Mailing Address - Phone:503-520-1363
Mailing Address - Fax:503-520-9533
Practice Address - Street 1:2715 SW 153RD DR
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97003-5106
Practice Address - Country:US
Practice Address - Phone:503-520-1363
Practice Address - Fax:503-520-9533
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FRESENIUS MEDICAL CARE HOLDINGS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-08
Last Update Date:2020-12-28
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
OR382521Medicare Oscar/Certification