Provider Demographics
NPI:1649623620
Name:WHITE EAGLE DIALYSIS CENTER
Entity type:Organization
Organization Name:WHITE EAGLE DIALYSIS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIALYSIS DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:580-765-2501
Mailing Address - Street 1:200 WHITE EAGLE DR
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-8315
Mailing Address - Country:US
Mailing Address - Phone:580-765-2501
Mailing Address - Fax:580-765-6348
Practice Address - Street 1:200 WHITE EAGLE DR
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-8315
Practice Address - Country:US
Practice Address - Phone:580-765-2501
Practice Address - Fax:580-765-6348
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PONCA TRIBE OF OKLAHOMA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-07-14
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment