Provider Demographics
NPI:1235667130
Name:CONECUH DIALYSIS LLC
Entity Type:Organization
Organization Name:CONECUH DIALYSIS LLC
Other - Org Name:LAUREL LAKES 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:
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:615-320-4214
Mailing Address - Fax:866-944-3352
Practice Address - Street 1:14500 LAUREL PL
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-4961
Practice Address - Country:US
Practice Address - Phone:301-497-5454
Practice Address - Fax:301-776-2531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-23
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment