Provider Demographics
NPI:1992994891
Name:LOCKPORT DIALYSIS LLC
Entity type:Organization
Organization Name:LOCKPORT DIALYSIS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF ACCOUNTING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:K
Authorized Official - Last Name:HILGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-733-4500
Mailing Address - Street 1:5200 VIRGINIA WAY
Mailing Address - Street 2:STE 400 L&C
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-7569
Mailing Address - Country:US
Mailing Address - Phone:615-341-6657
Mailing Address - Fax:866-651-9495
Practice Address - Street 1:16626 W 159TH ST
Practice Address - Street 2:STE 703
Practice Address - City:LOCKPORT
Practice Address - State:IL
Practice Address - Zip Code:60441-8018
Practice Address - Country:US
Practice Address - Phone:815-838-2918
Practice Address - Fax:815-838-4754
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-17
Last Update Date:2013-04-18
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
IL=========001Medicaid
IL=========001Medicaid