Provider Demographics
NPI:1942551643
Name:SOUTH ARLINGTON DIALYSIS CENTER LLC
Entity Type:Organization
Organization Name:SOUTH ARLINGTON DIALYSIS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF NURSING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SARA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:BRADY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-371-7878
Mailing Address - Street 1:3415 S COOPER ST
Mailing Address - Street 2:SUITE 118
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76015-3434
Mailing Address - Country:US
Mailing Address - Phone:817-465-8585
Mailing Address - Fax:817-467-3520
Practice Address - Street 1:3415 S COOPER ST
Practice Address - Street 2:SUITE 118
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76015-3434
Practice Address - Country:US
Practice Address - Phone:817-465-8585
Practice Address - Fax:817-467-3520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-21
Last Update Date:2023-01-13
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
TX315776001Medicaid
TX315776001Medicaid