1912536384 NPI number — TRAVILLE 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 1912536384 NPI number — TRAVILLE DIALYSIS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRAVILLE 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:
1912536384
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/08/2023
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:
615-320-4593
Provider Business Mailing Address Fax Number:
800-293-5872

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
196 SLOANE GARDEN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOILING SPRINGS
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29316-1929
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-814-7395
Provider Business Practice Location Address Fax Number:
864-814-7899
Provider Enumeration Date:
04/07/2020

Additional Information

Authorized Official

Authorized Official Last Name:
WEY
Authorized Official First Name:
SAMUEL
Authorized Official Middle Name:
T.
Authorized Official Title or Position:
SR DIRECTOR 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: RE0102 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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