Basic Information
| Provider Information | |||||||||
| NPI: | 1639655616 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HOME DIALYSIS THERAPIES, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5811 W IVYBRIDGE PL | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616159289 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145609648 | ||||||||
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| Practice Location | |||||||||
| Address1: | 216 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | HAVANA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 626441138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096426705 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2018 | ||||||||
| LastUpdateDate: | 07/12/2018 | ||||||||
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| AuthorizedOfficialLastName: | USMAN | ||||||||
| AuthorizedOfficialFirstName: | AHSAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3145609648 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QH0100X | Y | Ambulatory Health Care Facilities | Clinic/Center | Health Service |
No ID Information.