| Organization Name: | LIBERTY DIALYSIS - HAYDEN, LLC |
| NPI Number: | 1174711881 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | THOMAS L. WEINBERG (AUTHORIZED OFFICIAL) |
| Mailing Address: | 8556 N Wayne Dr Hayden |
| State: | ID US |
| Postal Code: | 838355068 |
| Phone Number: | 2087627724 |
| Fax Number: | 2087627774 |
| NPI Enumeration Date: | 10/09/2007 |
| NPI Last Update Date: | 03/31/2016 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QE0700X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | End-Stage Renal Disease (ESRD) Treatment |
| Taxonomy Definition: | |