Provider Demographics
NPI:1083695357
Name:DIALYSIS CENTERS OF DAYTON, LLC
Entity Type:Organization
Organization Name:DIALYSIS CENTERS OF DAYTON, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:JAYME
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-499-8850
Mailing Address - Street 1:136 S LUDLOW ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45402-1813
Mailing Address - Country:US
Mailing Address - Phone:937-499-8850
Mailing Address - Fax:937-223-9615
Practice Address - Street 1:4700 SPRINGBORO PIKE
Practice Address - Street 2:
Practice Address - City:MORAINE
Practice Address - State:OH
Practice Address - Zip Code:45439-1964
Practice Address - Country:US
Practice Address - Phone:937-499-8850
Practice Address - Fax:937-223-9615
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-14
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000002892OtherBLUE CROSS/BLUE SHIELD
OH13791OtherCARESOURCE
OH2178638Medicaid
OH6820003OtherUNITED HEALTHCARE
OH2178638Medicaid
OH362517Medicare ID - Type Unspecified