Basic Information
| Provider Information | |||||||||
| NPI: | 1538400239 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PONCA DIALYSIS LLC | ||||||||
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| OtherOrganizationName: | TULLY ROAD 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: | 6152383085 | ||||||||
| FaxNumber: | 8002689682 | ||||||||
| Practice Location | |||||||||
| Address1: | 1290 TULLY RD | ||||||||
| Address2: | STE 60 | ||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951223069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4082750105 | ||||||||
| FaxNumber: | 4082750115 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2013 | ||||||||
| LastUpdateDate: | 03/17/2022 | ||||||||
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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: | 03/17/2022 | ||||||||
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 | 1538400239 | 05 | CA | MEDICAID |