1780689505 NPI number — DIALYSIS CLINIC INC

Table of content: (NPI 1780689505)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780689505 NPI number — DIALYSIS CLINIC INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIALYSIS CLINIC 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:
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:
1780689505
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/05/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1616 HAYES ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NASHVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37203-3011
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-321-0212
Provider Business Mailing Address Fax Number:
615-321-4880

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1616 HAYES ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NASHVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37203-3011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-321-0212
Provider Business Practice Location Address Fax Number:
615-321-4880
Provider Enumeration Date:
06/17/2005

Additional Information

Authorized Official

Authorized Official Last Name:
SCHULTZ
Authorized Official First Name:
DONOVAN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
615-327-3061

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  TN 1952 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 05-3-TN-06-1 . This is a "ASHI LAB NUMBER" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 44D0659038 . This is a "CLIA" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: TN 1952 . This is a "STATE LABORATORY LICENSE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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