1235676677 NPI number — LABETTE DIALYSIS LLC

Table of content: (NPI 1235676677)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235676677 NPI number — LABETTE DIALYSIS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LABETTE 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:
LAWRENCE COUNTY 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:
1235676677
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/04/2024
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:
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:
615-238-3051
Provider Business Mailing Address Fax Number:
800-246-8346

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
367 COUNTY ROAD 406
Provider Second Line Business Practice Location Address:
UNIT 11
Provider Business Practice Location Address City Name:
SOUTH POINT
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45680-8766
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-894-0830
Provider Business Practice Location Address Fax Number:
877-288-1208
Provider Enumeration Date:
01/24/2017

Additional Information

Authorized Official

Authorized Official Last Name:
WEY
Authorized Official First Name:
SAMUEL
Authorized Official Middle Name:
T.
Authorized Official Title or Position:
VP, LICENSURE & CERTIFICATION
Authorized Official Telephone Number:
253-733-4501

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: 0320327 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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