1609952233 NPI number — PURITY DIALYSIS CENTERS, INC

Table of content: (NPI 1609952233)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609952233 NPI number — PURITY DIALYSIS CENTERS, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PURITY DIALYSIS CENTERS, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MENOMONEE FALLS DIALYSIS CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1609952233
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/26/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2301 SUN VALLEY DR STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DELAFIELD
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53018-2318
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-646-4162
Provider Business Mailing Address Fax Number:
262-646-2498

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
N87W17301 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MENOMONEE FALLS
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53051-2760
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-253-9768
Provider Business Practice Location Address Fax Number:
262-253-9870
Provider Enumeration Date:
10/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WALDRON
Authorized Official First Name:
TINA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
BILLING SUPERVISOR
Authorized Official Telephone Number:
262-646-6426

Provider Taxonomy Codes

  • Taxonomy code: 261QE0700X , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 52D0988770 . This is a "52D0988770" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 42054100 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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