Basic Information
| Provider Information | |||||||||
| NPI: | 1457599722 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HISTORIC DIALYSIS LLC | ||||||||
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| OtherOrganizationName: | FORREST CITY DIALYSIS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5200 VIRGINIA WAY | ||||||||
| Address2: | L&C DEPT 4TH FLOOR | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370277569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153204521 | ||||||||
| FaxNumber: | 8665942894 | ||||||||
| Practice Location | |||||||||
| Address1: | 1501 N WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | FORREST CITY | ||||||||
| State: | AR | ||||||||
| PostalCode: | 723352152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8704944022 | ||||||||
| FaxNumber: | 8704944769 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2009 | ||||||||
| LastUpdateDate: | 10/29/2009 | ||||||||
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| AuthorizedOfficialLastName: | HILGER | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2533821919 | ||||||||
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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.