Basic Information
Provider Information | |||||||||
NPI: | 1669650545 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PURITY DIALYSIS CENTERS INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PURITY HOME TRAINING PROGRAM | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2301 SUN VALLEY DR STE 200 | ||||||||
Address2: |   | ||||||||
City: | DELAFIELD | ||||||||
State: | WI | ||||||||
PostalCode: | 530182318 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2626466426 | ||||||||
FaxNumber: | 2626462498 | ||||||||
Practice Location | |||||||||
Address1: | 2301 SUN VALLEY DR STE 101 | ||||||||
Address2: |   | ||||||||
City: | DELAFIELD | ||||||||
State: | WI | ||||||||
PostalCode: | 530182318 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2626466426 | ||||||||
FaxNumber: | 2626462498 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/04/2008 | ||||||||
LastUpdateDate: | 10/28/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WALDRON | ||||||||
AuthorizedOfficialFirstName: | TINA | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | BILLING SUPERVISOR | ||||||||
AuthorizedOfficialTelephone: | 2626466426 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
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 | 52D1091140 | 01 | WI | CLIA ID NUMBER | OTHER | 1669650545 | 05 | WI |   | MEDICAID |