Provider Demographics
NPI:1255787115
Name:ADVANCED DIALYSIS CENTER, LLC
Entity type:Organization
Organization Name:ADVANCED DIALYSIS CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MINESSIA
Authorized Official - Middle Name:ZARITA
Authorized Official - Last Name:PEARSON
Authorized Official - Suffix:
Authorized Official - Credentials:MSN
Authorized Official - Phone:301-577-1007
Mailing Address - Street 1:9320 ANNAPOLIS RD
Mailing Address - Street 2:
Mailing Address - City:LANHAM
Mailing Address - State:MD
Mailing Address - Zip Code:20706-3100
Mailing Address - Country:US
Mailing Address - Phone:301-577-1007
Mailing Address - Fax:
Practice Address - Street 1:610 DUTCHMANS LN
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:MD
Practice Address - Zip Code:21601-3346
Practice Address - Country:US
Practice Address - Phone:410-820-9873
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADVANCED DIALYSIS CENTER, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-05-10
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDE2649261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD4112326Medicaid