Basic Information
| Provider Information | |||||||||
| NPI: | 1164028627 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WAHCONAH DIALYSIS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5200 VIRGINIA WAY | ||||||||
| Address2: | L AND C DEPT | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370277569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153204414 | ||||||||
| FaxNumber: | 8668652884 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 WASHINGTON AVE STE F | ||||||||
| Address2: | |||||||||
| City: | MANAHAWKIN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080502861 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6098913070 | ||||||||
| FaxNumber: | 6098913095 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2020 | ||||||||
| LastUpdateDate: | 12/09/2020 | ||||||||
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| AuthorizedOfficialLastName: | WINSTEL | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF ACCOUNTING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6153204414 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DAVITA INC | ||||||||
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| NPICertificationDate: | 12/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
No ID Information.