Provider Demographics
NPI:1801160809
Name:FORT LAUDERDALE RENAL DIALYSIS LLC
Entity type:Organization
Organization Name:FORT LAUDERDALE RENAL DIALYSIS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR. VP OF CLINICAL & REGULATORY
Authorized Official - Prefix:
Authorized Official - First Name:SHARI
Authorized Official - Middle Name:K
Authorized Official - Last Name:COUSINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-922-3080
Mailing Address - Street 1:6264 N FEDERAL HWY
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-1904
Mailing Address - Country:US
Mailing Address - Phone:954-776-3791
Mailing Address - Fax:954-771-7527
Practice Address - Street 1:6264 N FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-1904
Practice Address - Country:US
Practice Address - Phone:954-776-3791
Practice Address - Fax:954-771-7527
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-08
Last Update Date:2020-03-16
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
FL005936600Medicaid
FL005936600Medicaid