Provider Demographics
NPI:1922000587
Name:THE DIALYSIS COTTAGE LLC
Entity Type:Organization
Organization Name:THE DIALYSIS COTTAGE LLC
Other - Org Name:THE DIALYSIS COTTAGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TRISH
Authorized Official - Middle Name:A
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:RN, CNN
Authorized Official - Phone:940-612-1642
Mailing Address - Street 1:1902 HOSPITAL BLVD
Mailing Address - Street 2:SUITE D
Mailing Address - City:GAINESVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76240-2007
Mailing Address - Country:US
Mailing Address - Phone:940-612-1642
Mailing Address - Fax:940-612-2360
Practice Address - Street 1:1902 HOSPITAL BLVD
Practice Address - Street 2:SUITE D
Practice Address - City:GAINESVILLE
Practice Address - State:TX
Practice Address - Zip Code:76240-2007
Practice Address - Country:US
Practice Address - Phone:940-612-1642
Practice Address - Fax:940-612-2360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-12
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX008551261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX193949801Medicaid
TX008551OtherDSHS
TX193949801Medicaid