Provider Demographics
NPI:1952676033
Name:NEW SMYRNA BEACH DIALYSIS LLC
Entity Type:Organization
Organization Name:NEW SMYRNA BEACH DIALYSIS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:MCDONOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-922-3080
Mailing Address - Street 1:821 STATE ROAD 44
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32168-7271
Mailing Address - Country:US
Mailing Address - Phone:386-409-8855
Mailing Address - Fax:386-409-8755
Practice Address - Street 1:821 STATE ROAD 44
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32168-7271
Practice Address - Country:US
Practice Address - Phone:386-409-8855
Practice Address - Fax:386-409-8755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-21
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment