Provider Demographics
NPI:1750709838
Name:CENTRAL LITTLE ROCK DIALYSIS
Entity type:Organization
Organization Name:CENTRAL LITTLE ROCK DIALYSIS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KENT
Authorized Official - Middle Name:
Authorized Official - Last Name:THIRY
Authorized Official - Suffix:
Authorized Official - Credentials:CHAIRMAN
Authorized Official - Phone:303-876-6000
Mailing Address - Street 1:6 FREEWAY DR
Mailing Address - Street 2:STE 100
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72204-2486
Mailing Address - Country:US
Mailing Address - Phone:501-664-6754
Mailing Address - Fax:
Practice Address - Street 1:1423 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-4203
Practice Address - Country:US
Practice Address - Phone:253-382-1752
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-04
Last Update Date:2014-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1376516039261QE0700X
AR04D1004570261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR150329734Medicaid