1710439187 NPI number — PETRA DIALYSIS LLC

Table of content: (NPI 1710439187)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710439187 NPI number — PETRA DIALYSIS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PETRA 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:
1710439187
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/10/2024
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:
615-238-3085
Provider Business Mailing Address Fax Number:
800-268-9682

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
82900 AVENUE 42
Provider Second Line Business Practice Location Address:
STE E
Provider Business Practice Location Address City Name:
INDIO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92203-9658
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-342-6842
Provider Business Practice Location Address Fax Number:
760-342-6807
Provider Enumeration Date:
11/01/2016

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:
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: 1710439187 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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