Provider Demographics
NPI:1205869682
Name:DIALYSIS CLINIC INC.
Entity type:Organization
Organization Name:DIALYSIS CLINIC INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DONOVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHULTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-327-3061
Mailing Address - Street 1:806 MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:MEXICO
Mailing Address - State:MO
Mailing Address - Zip Code:65265-3728
Mailing Address - Country:US
Mailing Address - Phone:573-581-2638
Mailing Address - Fax:573-581-4279
Practice Address - Street 1:806 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:MEXICO
Practice Address - State:MO
Practice Address - Zip Code:65265-3728
Practice Address - Country:US
Practice Address - Phone:573-581-2638
Practice Address - Fax:573-581-4279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2023-10-04
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
MO501565147Medicaid
MO501565147Medicaid