Provider Demographics
NPI:1396924957
Name:LIBERTY DIALYSIS-WOODS CROSS LLC
Entity type:Organization
Organization Name:LIBERTY DIALYSIS-WOODS CROSS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BLANTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-699-9000
Mailing Address - Street 1:572 W 750 S BLDG B
Mailing Address - Street 2:
Mailing Address - City:WOODS CROSS
Mailing Address - State:UT
Mailing Address - Zip Code:84010-7265
Mailing Address - Country:US
Mailing Address - Phone:801-292-2658
Mailing Address - Fax:801-292-2670
Practice Address - Street 1:572 W 750 S BLDG B
Practice Address - Street 2:
Practice Address - City:WOODS CROSS
Practice Address - State:UT
Practice Address - Zip Code:84010-7265
Practice Address - Country:US
Practice Address - Phone:801-292-2658
Practice Address - Fax:801-292-2670
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FRESENIUS MEDICAL CARE HOLDINGS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-10-31
Last Update Date:2023-10-18
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
UT462538Medicare Oscar/Certification