Basic Information
| Provider Information | |||||||||
| NPI: | 1891162301 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KINGSTON DIALYSIS LLC | ||||||||
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| OtherOrganizationName: | BOULDER DIALYSIS CENTER | ||||||||
| 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: | 6153416264 | ||||||||
| FaxNumber: | 8002972925 | ||||||||
| Practice Location | |||||||||
| Address1: | 2880 FOLSOM ST STE 110 | ||||||||
| Address2: | |||||||||
| City: | BOULDER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034405600 | ||||||||
| FaxNumber: | 3034404165 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2015 | ||||||||
| LastUpdateDate: | 03/10/2021 | ||||||||
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| AuthorizedOfficialLastName: | WINSTEL | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF ACCOUNTING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2537334501 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | 120301 | CO | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
ID Information
| ID | Type | State | Issuer | Description | 120301 | 01 | CO | STATE LICENSE | OTHER | 1891162301 | 05 | CO | MEDICAID |