Provider Demographics
NPI:1073839296
Name:CERITO DIALYSIS PARTNERS LLC
Entity Type:Organization
Organization Name:CERITO DIALYSIS PARTNERS LLC
Other - Org Name:WOLF RIVER DIALYSIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP LICENSURE & CERTIFICATION
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:WEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-341-6641
Mailing Address - Street 1:5200 VIRGINIA WAY
Mailing Address - Street 2:L&C DEPT
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-7569
Mailing Address - Country:US
Mailing Address - Phone:615-320-4514
Mailing Address - Fax:866-594-9961
Practice Address - Street 1:7990 TRINITY RD
Practice Address - Street 2:STE 101
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38018-7730
Practice Address - Country:US
Practice Address - Phone:901-751-3120
Practice Address - Fax:901-751-3223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-13
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN202261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0442709Medicaid
TN0442709Medicaid