Provider Demographics
NPI:1154351120
Name:DELRAY BEACH DIALYSIS CENTER LLC
Entity type:Organization
Organization Name:DELRAY BEACH DIALYSIS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:BOUCHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-922-3080
Mailing Address - Street 1:5130 LINTON BLVD
Mailing Address - Street 2:SUITE G-4
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33484-6596
Mailing Address - Country:US
Mailing Address - Phone:561-498-5959
Mailing Address - Fax:561-498-5949
Practice Address - Street 1:5130 LINTON BLVD
Practice Address - Street 2:SUITE G4
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33484-6596
Practice Address - Country:US
Practice Address - Phone:561-498-5959
Practice Address - Fax:561-498-5949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2019-03-21
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
FL892299300Medicaid
FL102843Medicare Oscar/Certification