Provider Demographics
NPI:1538201850
Name:PURIFICARE DIALYSIS LLC
Entity type:Organization
Organization Name:PURIFICARE DIALYSIS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MATT
Authorized Official - Middle Name:
Authorized Official - Last Name:FREDERIC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-473-8300
Mailing Address - Street 1:15255 HEATHER STONE CT
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-3703
Mailing Address - Country:US
Mailing Address - Phone:760-473-8300
Mailing Address - Fax:
Practice Address - Street 1:801 AVENUE H E STE 110
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76011-7701
Practice Address - Country:US
Practice Address - Phone:817-709-4923
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment