Basic Information
| Provider Information | |||||||||
| NPI: | 1326647926 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AQUA DIALYSIS LEAGUE CITY, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1237 SOUTHRIDGE CT STE 203 | ||||||||
| Address2: | |||||||||
| City: | HURST | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760534305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6824294508 | ||||||||
| FaxNumber: | 3462146368 | ||||||||
| Practice Location | |||||||||
| Address1: | 2785 GULF FWY S STE 145 | ||||||||
| Address2: | |||||||||
| City: | LEAGUE CITY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775734996 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8323402404 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2020 | ||||||||
| LastUpdateDate: | 10/23/2020 | ||||||||
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| AuthorizedOfficialLastName: | PATEL | ||||||||
| AuthorizedOfficialFirstName: | RUPAL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8327212927 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | AQUA DIALYSIS LLP | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 10/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
No ID Information.