Basic Information
| Provider Information | |||||||||
| NPI: | 1093012544 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BRIDGES DIALYSIS LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | APPLESEED DIALYSIS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5200 VIRGINIA WAY | ||||||||
| Address2: | ATT: L&C DEPT | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370277569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153204514 | ||||||||
| FaxNumber: | 8665949961 | ||||||||
| Practice Location | |||||||||
| Address1: | 1833 MAGNAVOX WAY | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468041539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604321036 | ||||||||
| FaxNumber: | 2604322085 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/18/2011 | ||||||||
| LastUpdateDate: | 10/04/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WINSTEL | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF ACCOUNTING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2537334501 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/30/2022 | ||||||||
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 | 201048220 A | 05 | IN | MEDICAID |