Provider Demographics
NPI:1316175326
Name:BOARDMAN DIALYSIS CENTER LLC
Entity type:Organization
Organization Name:BOARDMAN DIALYSIS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF NURSING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SARA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:BRADY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-371-7878
Mailing Address - Street 1:7153 TIFFANY BLVD
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44514-1965
Mailing Address - Country:US
Mailing Address - Phone:330-729-1355
Mailing Address - Fax:330-729-1377
Practice Address - Street 1:7153 TIFFANY BLVD
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44514-1965
Practice Address - Country:US
Practice Address - Phone:330-729-1355
Practice Address - Fax:330-729-1377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-29
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3093647Medicaid
OH362761Medicare Oscar/Certification