Provider Demographics
NPI:1770700171
Name:SOUTHWEST KIDNEY DIALYSIS, LLC
Entity type:Organization
Organization Name:SOUTHWEST KIDNEY DIALYSIS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHEIF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MAUVAIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-610-6110
Mailing Address - Street 1:2149 E WARNER RD
Mailing Address - Street 2:STE 112
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85284-3494
Mailing Address - Country:US
Mailing Address - Phone:480-610-6100
Mailing Address - Fax:480-610-6195
Practice Address - Street 1:20325 N 51ST AVE
Practice Address - Street 2:BUILDING 11, SUITE 186
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-5674
Practice Address - Country:US
Practice Address - Phone:623-533-6521
Practice Address - Fax:623-533-6579
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2007-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment