Provider Demographics
NPI:1184117103
Name:LIFEALYSIS KIDNEY CARE, LLC
Entity type:Organization
Organization Name:LIFEALYSIS KIDNEY CARE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FACILITY ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:
Authorized Official - Last Name:COMPLE
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:713-569-3961
Mailing Address - Street 1:4300 FAIRMONT PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:TX
Mailing Address - Zip Code:77504-3306
Mailing Address - Country:US
Mailing Address - Phone:832-617-8816
Mailing Address - Fax:713-513-5394
Practice Address - Street 1:4300 FAIRMONT PKWY STE 100
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:TX
Practice Address - Zip Code:77504
Practice Address - Country:US
Practice Address - Phone:832-617-8816
Practice Address - Fax:713-513-5394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-13
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX110508OtherESRD LICENSE
TX1976747OtherNOVITAS