Provider Demographics
NPI:1720435662
Name:FORTBEND DIALYSIS RENAL INC.
Entity Type:Organization
Organization Name:FORTBEND DIALYSIS RENAL INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:VOUKEP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-246-4306
Mailing Address - Street 1:12220 MURPHY RD STE R
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:TX
Mailing Address - Zip Code:77477-2410
Mailing Address - Country:US
Mailing Address - Phone:281-568-9911
Mailing Address - Fax:281-568-0093
Practice Address - Street 1:12220 MURPHY RD STE R
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:TX
Practice Address - Zip Code:77477-2410
Practice Address - Country:US
Practice Address - Phone:281-568-9911
Practice Address - Fax:281-568-0093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-20
Last Update Date:2018-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX110390261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment