NPIMap

Organization Active NPI

Southeastern Renal Dialysis L.C.

  • End-Stage Renal Disease (ESRD) Treatment Clinic/Center
  • West Burlington, IA
National Provider Identifier
1659337541
Registry record updated Mar 16, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
End-Stage Renal Disease (ESRD) Treatment Clinic/CenterTaxonomy code 261QE0700X
Legal business name
SOUTHEASTERN RENAL DIALYSIS L.C.
Practice address
1213 S Gear Ave
West Burlington, IA 52655-1679
Phone
(319) 758-0691
Fax
(319) 758-0392
NPI assigned
Apr 21, 2006
Organization subpart
Yes
Parent organization
SOUTHEASTERN RENAL DIALYSIS L.C.As reported in NPPES

NPPES NPI Registry

Updated by the provider on Mar 16, 2012

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mrs. Mary Liechty
Title
Administrator
Phone
(319) 385-6728

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
End-Stage Renal Disease (ESRD) Treatment Clinic/Center 261QE0700X IA Primary

Addresses

Primary practice location

1213 S Gear Ave
West Burlington, IA 52655-1679

Mailing address

507 S White St
Mt Pleasant, IA 52641-2625

Other identifiers 1

IdentifierTypeStateIssuer
0625103MedicaidIA

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20120206000388 IA Part A Provider - End-Stage Renal Disease Facility (ESRD) 6608871249 Practice locations: W Burlington, IA

Other NPIs with the same Medicare PAC ID 4

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Care Compare: Dialysis facility

Medicare Care Compare
Listed as
Southeastern Renal Dialysis, LC - W BurlingtonCCN 162512
Overall star rating
2.0 of 5
Ownership
Profit
Certified
Sep 30, 1997
Medicare certification status
ActiveFrom the Provider of Services file
Dialysis stations
12

Name & address match This facility record has no NPI; it was connected to this NPI by matching name and address.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
16D0993560Southeastern Renal Dialysis1213 South Gear Avenue, West Burlington, IA 52655Certificate of waiverMar 26, 2028

National Provider Directory

National Provider Directory
Tax ID family
Southeastern Renal Dialysis LC5 organizations share this tax ID, including this one
Part of
Southeastern Renal Dialysis LC

Other organizations with this tax ID 4

Organizations that report the same tax identification number in the National Provider Directory.

Member of 2

Organizations this organization is a member of, according to the National Provider Directory.

Locations

2000A S Main St
Fairfield, IA 52556
Phone (641) 469-3313

507 S White St
Mt Pleasant, IA 52641
Phone (319) 385-6720

1213 S Gear Ave
West Burlington, IA 52655
Phone (319) 758-0691

Practitioners & affiliated clinicians

Affiliated clinicians 3

Clinicians who list this facility as an affiliation in Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1145577600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1331856000000",
    "number": "1659337541",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "507 S WHITE ST",
            "city": "MT PLEASANT",
            "state": "IA",
            "postal_code": "526412625"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1213 S GEAR AVE",
            "city": "WEST BURLINGTON",
            "state": "IA",
            "postal_code": "526551679",
            "telephone_number": "319-758-0691",
            "fax_number": "319-758-0392"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHEASTERN RENAL DIALYSIS L.C.",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "SOUTHEASTERN RENAL DIALYSIS L.C.",
        "enumeration_date": "2006-04-21",
        "last_updated": "2012-03-16",
        "status": "A",
        "authorized_official_last_name": "LIECHTY",
        "authorized_official_first_name": "MARY",
        "authorized_official_title_or_position": "ADMINISTRATOR",
        "authorized_official_telephone_number": "319-385-6728",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "261QE0700X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, End-Stage Renal Disease (ESRD) Treatment",
            "state": "IA",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0625103",
            "state": "IA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in West Burlington, IA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 16, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.