Provider Demographics
NPI:1851569529
Name:LIBERTY DIALYSIS - OKLAHOMA CITY LLC
Entity Type:Organization
Organization Name:LIBERTY DIALYSIS - OKLAHOMA CITY LLC
Other - Org Name:LIBERTY DIALYSIS - MERCY DIALYSIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:B
Authorized Official - Last Name:PARDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-236-5001
Mailing Address - Street 1:7650 SE 27TH ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MERCER ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98040-3060
Mailing Address - Country:US
Mailing Address - Phone:206-236-5001
Mailing Address - Fax:
Practice Address - Street 1:7650 SE 27TH ST
Practice Address - Street 2:SUITE 200
Practice Address - City:MERCER ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98040-3060
Practice Address - Country:US
Practice Address - Phone:206-236-5001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-15
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment