Provider Demographics
NPI:1093071821
Name:SOUTHWEST KIDNEY DAVITA DIALYSIS PARTNERS LLC
Entity Type:Organization
Organization Name:SOUTHWEST KIDNEY DAVITA DIALYSIS PARTNERS LLC
Other - Org Name:WICKENBURG DIALYSIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF ACCOUNTING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:D
Authorized Official - Last Name:WINSTEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-733-4501
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:615-341-6814
Mailing Address - Fax:800-293-8405
Practice Address - Street 1:811 N TEGNER ST
Practice Address - Street 2:SUITES 101, 103, 105, 107
Practice Address - City:WICKENBURG
Practice Address - State:AZ
Practice Address - Zip Code:85390-5409
Practice Address - Country:US
Practice Address - Phone:928-684-6898
Practice Address - Fax:928-684-6107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-05
Last Update Date:2022-04-18
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
AZ787101Medicaid
AZ032637Medicare Oscar/Certification