Basic Information
| Provider Information | |||||||||
| NPI: | 1053689034 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RAYBURN DIALYSIS LLC | ||||||||
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| OtherOrganizationName: | ODESSA DIALYSIS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5200 VIRGINIA WAY | ||||||||
| Address2: | L&C DEPT | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370277569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153204550 | ||||||||
| FaxNumber: | 8665008578 | ||||||||
| Practice Location | |||||||||
| Address1: | 6005 EASTRIDGE RD | ||||||||
| Address2: | |||||||||
| City: | ODESSA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 797625019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4323623008 | ||||||||
| FaxNumber: | 4323623302 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2011 | ||||||||
| LastUpdateDate: | 12/21/2012 | ||||||||
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| AuthorizedOfficialLastName: | HILGER | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF ACCOUNTING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2533821919 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | 110111 | TX | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
ID Information
| ID | Type | State | Issuer | Description | 297639101 | 05 | TX | MEDICAID | 027740 | 01 | TX | KIDNEY PROGRAM | OTHER |