Provider Demographics
NPI:1063941565
Name:PRIME DIALYSIS, LLC
Entity type:Organization
Organization Name:PRIME DIALYSIS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MS
Authorized Official - First Name:MIMI
Authorized Official - Middle Name:
Authorized Official - Last Name:BARRERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-778-8277
Mailing Address - Street 1:100 EAST SAMPLE ROAD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33064
Mailing Address - Country:US
Mailing Address - Phone:954-781-7741
Mailing Address - Fax:888-349-8679
Practice Address - Street 1:12200 WEST COLONIAL DRIVE
Practice Address - Street 2:SUITE 102
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787
Practice Address - Country:US
Practice Address - Phone:954-781-7741
Practice Address - Fax:888-349-8679
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-08
Last Update Date:2017-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment