Basic Information
| Provider Information | |||||||||
| NPI: | 1831560077 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HOLTEN DIALYSIS LLC | ||||||||
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| OtherOrganizationName: | SERRANO DIALYSIS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5200 VIRGINIA WAY | ||||||||
| Address2: | ATT: L&C DEPT | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370277569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152383085 | ||||||||
| FaxNumber: | 8002689682 | ||||||||
| Practice Location | |||||||||
| Address1: | 1800 MEDICAL CENTER DR | ||||||||
| Address2: | STE 150 | ||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924111218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098872717 | ||||||||
| FaxNumber: | 9098873794 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2015 | ||||||||
| LastUpdateDate: | 08/04/2022 | ||||||||
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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: | 07/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
No ID Information.