1174902779 NPI number — WEST ORANGE WINTER GARDEN DIALYSIS CENTER, 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 1174902779 NPI number — WEST ORANGE WINTER GARDEN DIALYSIS CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WEST ORANGE WINTER GARDEN DIALYSIS CENTER, 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:
Provider Other Organization Name Type Code:
6
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:
1174902779
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/23/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
301 S WEST CROWN POINT RD
Provider Second Line Business Mailing Address:
STE 130
Provider Business Mailing Address City Name:
WINTER GARDEN
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34787-2950
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-378-5955
Provider Business Mailing Address Fax Number:
888-866-3359

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
301 S WEST CROWN POINT RD
Provider Second Line Business Practice Location Address:
STE 130
Provider Business Practice Location Address City Name:
WINTER GARDEN
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34787-2950
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-378-5955
Provider Business Practice Location Address Fax Number:
888-866-3359
Provider Enumeration Date:
05/28/2015

Additional Information

Authorized Official

Authorized Official Last Name:
BLANTON
Authorized Official First Name:
BARRY
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
781-699-9000

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: 016961200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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