Provider Demographics
NPI:1699913376
Name:HERITAGE DIALYSIS CENTER LLC
Entity type:Organization
Organization Name:HERITAGE 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 1:67 COOPER ST
Mailing Address - Street 2:
Mailing Address - City:AGAWAM
Mailing Address - State:MA
Mailing Address - Zip Code:01001-2149
Mailing Address - Country:US
Mailing Address - Phone:413-786-2022
Mailing Address - Fax:413-786-2111
Practice Address - Street 1:67 COOPER ST
Practice Address - Street 2:
Practice Address - City:AGAWAM
Practice Address - State:MA
Practice Address - Zip Code:01001-2149
Practice Address - Country:US
Practice Address - Phone:413-786-2022
Practice Address - Fax:413-786-2111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-03
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
MA110085307AMedicaid
MA110085307AMedicaid