Provider Demographics
NPI:1699051037
Name:SPACE CITY DIALYSIS CENTER LLC
Entity type:Organization
Organization Name:SPACE CITY 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 1:6518 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:TEXAS CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77591-4056
Mailing Address - Country:US
Mailing Address - Phone:409-965-0318
Mailing Address - Fax:409-965-0319
Practice Address - Street 1:6518 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:TEXAS CITY
Practice Address - State:TX
Practice Address - Zip Code:77591-4056
Practice Address - Country:US
Practice Address - Phone:409-965-0318
Practice Address - Fax:409-965-0319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-31
Last Update Date:2023-01-10
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
TX332410501Medicaid
TX332410501Medicaid