Provider Demographics
NPI:1720383219
Name:JOHNSON DIALYSIS CENTER OF DAVIE FLORIDA LLC
Entity type:Organization
Organization Name:JOHNSON DIALYSIS CENTER OF DAVIE FLORIDA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:CARRASCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-962-9640
Mailing Address - Street 1:3105 N UNIVERSITY DR
Mailing Address - Street 2:SUITE 3
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33024-2222
Mailing Address - Country:US
Mailing Address - Phone:954-962-9640
Mailing Address - Fax:954-962-9641
Practice Address - Street 1:3105 NORTH UNIVERSITY DRIVE
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33024
Practice Address - Country:US
Practice Address - Phone:954-962-9640
Practice Address - Fax:954-962-9641
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-14
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment