Provider Demographics
NPI:1184132425
Name:INNOVATIVE DIALYSIS SOLUTIONS AT HOME OF DEVINE
Entity type:Organization
Organization Name:INNOVATIVE DIALYSIS SOLUTIONS AT HOME OF DEVINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:NAIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-626-1117
Mailing Address - Street 1:915 S LAREDO ST STE 200
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78204-3211
Mailing Address - Country:US
Mailing Address - Phone:210-277-1418
Mailing Address - Fax:
Practice Address - Street 1:108 S. UPSON DRIVE
Practice Address - Street 2:
Practice Address - City:DEVINE
Practice Address - State:TX
Practice Address - Zip Code:78016
Practice Address - Country:US
Practice Address - Phone:830-541-5372
Practice Address - Fax:830-267-8110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-22
Last Update Date:2022-05-07
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
TX3929473-01Medicaid