Basic Information
| Provider Information | |||||||||
| NPI: | 1033423173 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WAXLD LLC | ||||||||
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| OtherOrganizationName: | LIBERTY DIALYSIS - WAXAHACHIE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 844631 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752844631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2147362700 | ||||||||
| FaxNumber: | 2147362701 | ||||||||
| Practice Location | |||||||||
| Address1: | 1011 N HIGHWAY 77 | ||||||||
| Address2: | STE 102 | ||||||||
| City: | WAXAHACHIE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 751651798 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9723518575 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2010 | ||||||||
| LastUpdateDate: | 01/13/2016 | ||||||||
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| AuthorizedOfficialLastName: | PARDO | ||||||||
| AuthorizedOfficialFirstName: | RYAN | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2062365001 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | U.S. RENAL CARE, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
ID Information
| ID | Type | State | Issuer | Description | 283724701 | 05 | TX | MEDICAID |