1982957064 NPI number — BLISS DIALYSIS LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982957064 NPI number — BLISS DIALYSIS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLISS DIALYSIS LLC
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:
BERKSHIRE HOME TRAINING
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:
1982957064
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/03/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5200 VIRGINIA WAY
Provider Second Line Business Mailing Address:
L&C DEPT
Provider Business Mailing Address City Name:
BRENTWOOD
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37027-7569
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-320-4268
Provider Business Mailing Address Fax Number:
877-238-0567

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4800 W SAN ANTONIO ST
Provider Second Line Business Practice Location Address:
STE 201
Provider Business Practice Location Address City Name:
BROKEN ARROW
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74012-6156
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-249-9716
Provider Business Practice Location Address Fax Number:
918-254-4173
Provider Enumeration Date:
10/26/2012

Additional Information

Authorized Official

Authorized Official Last Name:
WEY
Authorized Official First Name:
SAM
Authorized Official Middle Name:
Authorized Official Title or Position:
VP LICENSURE & CERTIFICATION
Authorized Official Telephone Number:
615-341-6641

Provider Taxonomy Codes

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

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

  • Identifier: 200518030A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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