1508100470 NPI number — DESERT ROCKS 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 1508100470 NPI number — DESERT ROCKS DIALYSIS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DESERT ROCKS 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:
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:
1508100470
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/29/2021
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:
615-341-6814
Provider Business Mailing Address Fax Number:
800-293-8405

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7362 W THUNDERBIRD RD
Provider Second Line Business Practice Location Address:
STE. 104
Provider Business Practice Location Address City Name:
PEORIA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85381-5028
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-486-0327
Provider Business Practice Location Address Fax Number:
623-878-5264
Provider Enumeration Date:
11/16/2012

Additional Information

Authorized Official

Authorized Official Last Name:
WINSTEL
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
D
Authorized Official Title or Position:
CHIEF ACCOUNTING OFFICER
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: 845332 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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