Provider Demographics
NPI:1336220250
Name:DIALYSIS CENTERS OF NORTHWEST ARKANSAS, LLC
Entity Type:Organization
Organization Name:DIALYSIS CENTERS OF NORTHWEST ARKANSAS, LLC
Other - Org Name:BENTON COUNTY DIALYSIS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:S
Authorized Official - Last Name:BOMSTAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-463-7000
Mailing Address - Street 1:801 SE PLAZA AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-7772
Mailing Address - Country:US
Mailing Address - Phone:479-273-7340
Mailing Address - Fax:
Practice Address - Street 1:801 SE PLAZA AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-7772
Practice Address - Country:US
Practice Address - Phone:479-273-7340
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2015-03-20
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
AR042575Medicare Oscar/Certification