Basic Information
| Provider Information | |||||||||
| NPI: | 1316179062 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BRIGHT DIALYSIS LLC | ||||||||
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| OtherOrganizationName: | BRIGHT DIALYSIS | ||||||||
| 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: | 6153204214 | ||||||||
| FaxNumber: | 8777358016 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 HARTMAN RD | ||||||||
| Address2: | |||||||||
| City: | FORT PIERCE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349474412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7724671117 | ||||||||
| FaxNumber: | 7725959340 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2009 | ||||||||
| LastUpdateDate: | 01/06/2016 | ||||||||
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| AuthorizedOfficialLastName: | ROTTURA | ||||||||
| AuthorizedOfficialFirstName: | SUE | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5616138830 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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 | 001826000 | 05 | FL | MEDICAID |