Basic Information
| Provider Information | |||||||||
| NPI: | 1932651155 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MISSION DIALYSIS SERVICES LLC | ||||||||
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| OtherOrganizationName: | PHYSICIANS DIALYSIS DENTON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19559 NE 10TH AVE | ||||||||
| Address2: | |||||||||
| City: | NORTH MIAMI BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331793501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056513261 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3305 UNICORN LAKE BLVD | ||||||||
| Address2: | |||||||||
| City: | DENTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762100102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9403874592 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2016 | ||||||||
| LastUpdateDate: | 11/04/2016 | ||||||||
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| AuthorizedOfficialLastName: | BOOTH | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3056513261 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PHYSICIANS DIALYSIS DENTON | ||||||||
| AuthorizedOfficialNamePrefix: | MISS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | 110282 | TX | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
No ID Information.