Basic Information
| Provider Information | |||||||||
| NPI: | 1275526113 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PERITONEAL DIALYSIS SUPPLY, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1964 BAYSHORE BLVD SUITE C | ||||||||
| Address2: | |||||||||
| City: | DUNEDIN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346982576 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7277385255 | ||||||||
| FaxNumber: | 7277330431 | ||||||||
| Practice Location | |||||||||
| Address1: | 1964 BAYSHORE BLVD | ||||||||
| Address2: | SUITE C | ||||||||
| City: | DUNEDIN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346982576 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7277385255 | ||||||||
| FaxNumber: | 7277330431 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2005 | ||||||||
| LastUpdateDate: | 04/10/2008 | ||||||||
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| AuthorizedOfficialLastName: | CLARK | ||||||||
| AuthorizedOfficialFirstName: | JUNE | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7277385255 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BD1200X | FL | Y | Suppliers | Durable Medical Equipment & Medical Supplies | Dialysis Equipment & Supplies |
No ID Information.