Provider Demographics
NPI:1932651155
Name:MISSION DIALYSIS SERVICES LLC
Entity Type:Organization
Organization Name:MISSION DIALYSIS SERVICES LLC
Other - Org Name:PHYSICIANS DIALYSIS DENTON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MISS
Authorized Official - First Name:GARY
Authorized Official - Middle Name:J
Authorized Official - Last Name:BOOTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-651-3261
Mailing Address - Street 1:19559 NE 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33179-3501
Mailing Address - Country:US
Mailing Address - Phone:305-651-3261
Mailing Address - Fax:
Practice Address - Street 1:3305 UNICORN LAKE BLVD
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76210-0102
Practice Address - Country:US
Practice Address - Phone:940-387-4592
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHYSICIANS DIALYSIS DENTON
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-11-04
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX110282261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment