1487730032 NPI number — PURITY DIALYSIS CENTERS, INC

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 1487730032 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:
WAUKESHA SOUTH 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:
1487730032
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/12/2010
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:
1260 SENTRY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAUKESHA
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53186-5930
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-446-5100
Provider Business Practice Location Address Fax Number:
262-446-5199
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: 52D0988781 . This is a "NBDC CLIA #" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 42056700 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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