Provider Demographics
NPI:1962683714
Name:DIALYSIS CARE CENTER OF PALM COAST LLC
Entity Type:Organization
Organization Name:DIALYSIS CARE CENTER OF PALM COAST LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR. VP OF CLINICAL & REGULATORY
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHARI
Authorized Official - Middle Name:
Authorized Official - Last Name:COUSINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-922-3080
Mailing Address - Street 1:515 PALM COAST PARKWAY SW
Mailing Address - Street 2:UNITS 2, 3, 4
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137-5700
Mailing Address - Country:US
Mailing Address - Phone:386-447-4477
Mailing Address - Fax:386-447-4476
Practice Address - Street 1:515 PALM COAST PKWY SW
Practice Address - Street 2:UNITS 2, 3, & 4
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-5700
Practice Address - Country:US
Practice Address - Phone:386-447-4477
Practice Address - Fax:386-447-4476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-21
Last Update Date:2020-03-10
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
102867Medicare Oscar/Certification