Provider Demographics
NPI:1093211609
Name:PATTISON DIALYSIS LLC
Entity Type:Organization
Organization Name:PATTISON DIALYSIS LLC
Other - Org Name:GRANT LINE 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:615-238-3085
Mailing Address - Fax:800-264-9682
Practice Address - Street 1:2955 N CORRAL HOLLOW RD
Practice Address - Street 2:STE 101
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95376-8800
Practice Address - Country:US
Practice Address - Phone:209-839-8302
Practice Address - Fax:209-839-8297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-03
Last Update Date:2024-01-18
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
CA1093211609Medicaid