Basic Information
| Provider Information | |||||||||
| NPI: | 1841237021 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EUMANA HOME DIALYSIS INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1313 LA CONCHA LN | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770541809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7136682744 | ||||||||
| FaxNumber: | 7137955959 | ||||||||
| Practice Location | |||||||||
| Address1: | 1313 LA CONCHA LN | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770541809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7136682744 | ||||||||
| FaxNumber: | 7137955959 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 07/22/2008 | ||||||||
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| AuthorizedOfficialLastName: | CLARK | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | AR SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 9365976467 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WN0300X | Y | 193400000X SINGLE SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 1242590001 | 01 | TX | DMERC | OTHER | 154141902 | 05 | TX | MEDICAID | HH6415 | 01 | TX | BCBS | OTHER | 531721 | 01 | TX | BCBS | OTHER |