1225380181 NPI number — WOOTEN DIALYSIS LLC

Table of content: (NPI 1225380181)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225380181 NPI number — WOOTEN DIALYSIS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WOOTEN 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:
CARLISLE REGIONAL DIALYSIS
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:
1225380181
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/10/2024
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:
615-341-6410
Provider Business Mailing Address Fax Number:
888-662-8259

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
419 VILLAGE DR
Provider Second Line Business Practice Location Address:
STE 10
Provider Business Practice Location Address City Name:
CARLISLE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17015-6943
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-218-5104
Provider Business Practice Location Address Fax Number:
717-241-0019
Provider Enumeration Date:
10/02/2012

Additional Information

Authorized Official

Authorized Official Last Name:
WEY
Authorized Official First Name:
SAMUEL
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: 102844600 0001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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