Basic Information
| Provider Information | |||||||||
| NPI: | 1669631297 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CANYONLANDS DIALYSIS LLC | ||||||||
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| OtherOrganizationName: | LEESBURG VIRGINIA DIALYSIS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5200 VIRGINIA WAY | ||||||||
| Address2: | STE 400 L&C | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370277569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153204521 | ||||||||
| FaxNumber: | 8665942894 | ||||||||
| Practice Location | |||||||||
| Address1: | 224 CORNWALL ST NW | ||||||||
| Address2: | |||||||||
| City: | LEESBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201762701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5712581362 | ||||||||
| FaxNumber: | 5712581342 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2008 | ||||||||
| LastUpdateDate: | 11/25/2008 | ||||||||
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| AuthorizedOfficialLastName: | HILGER | ||||||||
| AuthorizedOfficialFirstName: | JIM | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2533821919 | ||||||||
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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 | 1669631297 | 05 | VA | MEDICAID |