Provider Demographics
NPI:1902228513
Name:DIALYSIS CLINIC INC
Entity type:Organization
Organization Name:DIALYSIS CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DONOVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHULTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-327-3061
Mailing Address - Street 1:149 NORTH ST
Mailing Address - Street 2:MGMC - THAYER CAMPUS - DIALYSIS
Mailing Address - City:WATERVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04901-4974
Mailing Address - Country:US
Mailing Address - Phone:207-872-1291
Mailing Address - Fax:207-872-1091
Practice Address - Street 1:205 RIDGE RD
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:ME
Practice Address - Zip Code:04937-3376
Practice Address - Country:US
Practice Address - Phone:207-238-9321
Practice Address - Fax:207-238-9456
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-16
Last Update Date:2023-10-05
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
ME1902228513Medicaid