Provider Demographics
NPI:1982641692
Name:PREMIER STATEWIDE DIALYSIS INC
Entity Type:Organization
Organization Name:PREMIER STATEWIDE DIALYSIS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:A R SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:936-891-5572
Mailing Address - Street 1:1406 S CLARK RD
Mailing Address - Street 2:
Mailing Address - City:DUNCANVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75137
Mailing Address - Country:US
Mailing Address - Phone:972-709-1950
Mailing Address - Fax:972-709-1949
Practice Address - Street 1:1406 S CLARK RD
Practice Address - Street 2:
Practice Address - City:DUNCANVILLE
Practice Address - State:TX
Practice Address - Zip Code:75137
Practice Address - Country:US
Practice Address - Phone:972-709-1950
Practice Address - Fax:972-709-1949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX008102261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXHH6483OtherBC BS
TX672512Medicare ID - Type Unspecified