Provider Demographics
NPI:1912900044
Name:FORT SMITH REGIONAL DIALYSIS CENTER, LLC
Entity Type:Organization
Organization Name:FORT SMITH REGIONAL DIALYSIS CENTER, LLC
Other - Org Name:POTEAU DIALYSIS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:PALMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-755-6700
Mailing Address - Street 1:2201 BROOKEN HILL DR
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72908-8611
Mailing Address - Country:US
Mailing Address - Phone:479-755-6700
Mailing Address - Fax:479-755-6704
Practice Address - Street 1:1200 CENTRAL ST
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-2320
Practice Address - Country:US
Practice Address - Phone:918-647-9373
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-23
Last Update Date:2012-06-13
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
OK100707620AMedicaid
OK146670734Medicaid
OK900522191OtherPHYSICIAN'S
OK100707620AMedicaid
OK372559Medicare PIN
OK900522191Medicare ID - Type UnspecifiedOK MEDICARE