Basic Information
Provider Information | |||||||||
NPI: | 1821065749 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BRIGHTON DIALYSIS CENTER LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BRIGHTON DIALYSIS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5200 VIRGINIA WAY | ||||||||
Address2: | L&C DEPT | ||||||||
City: | BRENTWOOD | ||||||||
State: | TN | ||||||||
PostalCode: | 370277569 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6143416264 | ||||||||
FaxNumber: | 8002972925 | ||||||||
Practice Location | |||||||||
Address1: | 4700 E BROMLEY LANE | ||||||||
Address2: | SUITE 103 | ||||||||
City: | BRIGHTON | ||||||||
State: | CO | ||||||||
PostalCode: | 80601 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3036592511 | ||||||||
FaxNumber: | 3036592595 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/01/2006 | ||||||||
LastUpdateDate: | 11/02/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WINSTEL | ||||||||
AuthorizedOfficialFirstName: | JOHN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF ACCOUNTING OFFICER | ||||||||
AuthorizedOfficialTelephone: | 2537334501 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/02/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | 0221 | CO | Y |   | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
ID Information
ID | Type | State | Issuer | Description | 17182069 | 05 | CO |   | MEDICAID | 12S687 | 01 | CO | STATE LICENSE | OTHER |