Basic Information
| Provider Information | |||||||||
| NPI: | 1336155753 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHWEST KIDNEY DIALYSIS, LLC | ||||||||
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| OtherOrganizationName: | SOUTHWEST KIDNEY DIALYSIS - PHOENIX | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2149 E WARNER RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | TEMPE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852843494 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806106110 | ||||||||
| FaxNumber: | 6022539465 | ||||||||
| Practice Location | |||||||||
| Address1: | 337 E CORONADO RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850041580 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806106100 | ||||||||
| FaxNumber: | 4806106195 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 10/30/2007 | ||||||||
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| AuthorizedOfficialLastName: | MAUVAIS | ||||||||
| AuthorizedOfficialFirstName: | MICHELLE | ||||||||
| AuthorizedOfficialMiddleName: | R. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4806106110 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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 |
No ID Information.