Basic Information
| Provider Information | |||||||||
| NPI: | 1043552805 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EVERGLADES DIALYSIS LLC | ||||||||
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| OtherOrganizationName: | GRAYLING HOME TRAINING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5200 VIRGINIA WAY | ||||||||
| Address2: | L&C DEPT | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370277569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153204514 | ||||||||
| FaxNumber: | 8665949961 | ||||||||
| Practice Location | |||||||||
| Address1: | 125 E MICHIGAN AVE | ||||||||
| Address2: | |||||||||
| City: | GRAYLING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497381740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9893440805 | ||||||||
| FaxNumber: | 9893440785 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2013 | ||||||||
| LastUpdateDate: | 01/26/2022 | ||||||||
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| AuthorizedOfficialLastName: | WINSTEL | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF ACCOUNTING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2537334501 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
ID Information
| ID | Type | State | Issuer | Description | 1043552805 | 05 | MI | MEDICAID |