Provider Demographics
NPI:1841734720
Name:PHOENIX PEDIATRIC DIALYSIS CENTER LLC
Entity Type:Organization
Organization Name:PHOENIX PEDIATRIC DIALYSIS CENTER LLC
Other - Org Name:PEDIATRIC DIALYSIS CENTER OF PHOENIX
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR. VP OF CLINICAL & REGULATORY
Authorized Official - Prefix:
Authorized Official - First Name:SHARI
Authorized Official - Middle Name:K
Authorized Official - Last Name:COUSINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-922-3080
Mailing Address - Street 1:2545 E THOMAS RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-7969
Mailing Address - Country:US
Mailing Address - Phone:602-957-1648
Mailing Address - Fax:602-957-2196
Practice Address - Street 1:2545 E THOMAS RD
Practice Address - Street 2:SUITE 100
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-7969
Practice Address - Country:US
Practice Address - Phone:602-957-1648
Practice Address - Fax:602-957-2196
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-12
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment