Provider Demographics
NPI:1447620836
Name:DESERET PEAK DIALYSIS
Entity type:Organization
Organization Name:DESERET PEAK DIALYSIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:GENE
Authorized Official - Last Name:KIDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-930-0131
Mailing Address - Street 1:3333 S 900 E
Mailing Address - Street 2:STE 130
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-2087
Mailing Address - Country:US
Mailing Address - Phone:801-930-0131
Mailing Address - Fax:801-928-5454
Practice Address - Street 1:3333 S 900 E
Practice Address - Street 2:STE 130
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84106-2087
Practice Address - Country:US
Practice Address - Phone:801-930-0131
Practice Address - Fax:801-928-5454
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-29
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment