Provider Demographics
NPI:1053360925
Name:SOUTHWEST KIDNEY DIALYSIS, LLC
Entity type:Organization
Organization Name:SOUTHWEST KIDNEY DIALYSIS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFERY
Authorized Official - Middle Name:
Authorized Official - Last Name:WEINTRAUB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-610-6100
Mailing Address - Street 1:2149 E WARNER RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85284-3494
Mailing Address - Country:US
Mailing Address - Phone:480-610-6100
Mailing Address - Fax:
Practice Address - Street 1:20325 N 51ST AVE
Practice Address - Street 2:BUILDING 11 SUITE 184
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-5674
Practice Address - Country:US
Practice Address - Phone:623-533-3836
Practice Address - Fax:623-533-4033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-09
Last Update Date:2007-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3546261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ03-2604Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER