Provider Demographics
NPI:1487692950
Name:LIBERTY DIALYSIS - IDAHO FALLS LLC
Entity type:Organization
Organization Name:LIBERTY DIALYSIS - IDAHO FALLS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BLANTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-699-9000
Mailing Address - Street 1:2381 E SUNNYSIDE RD
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7521
Mailing Address - Country:US
Mailing Address - Phone:208-523-8500
Mailing Address - Fax:208-523-8502
Practice Address - Street 1:2381 E SUNNYSIDE RD
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7521
Practice Address - Country:US
Practice Address - Phone:208-523-8500
Practice Address - Fax:208-523-8502
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FRESENIUS MEDICAL CARE HOLDINGS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-04
Last Update Date:2023-10-17
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
ID132514Medicare Oscar/Certification