Provider Demographics
NPI:1801438130
Name:INTEGRA DIALYSIS CENTER LLC
Entity type:Organization
Organization Name:INTEGRA DIALYSIS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SOCORRO
Authorized Official - Middle Name:MIRYAM
Authorized Official - Last Name:MATHEWS
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:954-274-6045
Mailing Address - Street 1:6100 SW 183RD WAY
Mailing Address - Street 2:
Mailing Address - City:SOUTHWEST RANCHES
Mailing Address - State:FL
Mailing Address - Zip Code:33331-1640
Mailing Address - Country:US
Mailing Address - Phone:954-274-6045
Mailing Address - Fax:
Practice Address - Street 1:1490 W 49TH PL
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-3148
Practice Address - Country:US
Practice Address - Phone:954-274-6045
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-08
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment