Provider Demographics
NPI:1366829343
Name:WALLINGFORD DIALYSIS CARE LLC
Entity Type:Organization
Organization Name:WALLINGFORD DIALYSIS CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF NURSING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SARA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:BRADY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-371-7878
Mailing Address - Street 1:720 N MAIN STREET EXT STE 3
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-2788
Mailing Address - Country:US
Mailing Address - Phone:203-265-0667
Mailing Address - Fax:203-265-0669
Practice Address - Street 1:720 N MAIN STREET EXT STE 3
Practice Address - Street 2:
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-2788
Practice Address - Country:US
Practice Address - Phone:203-265-0667
Practice Address - Fax:203-265-0669
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-29
Last Update Date:2023-01-10
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
CT8063906Medicaid
CT8063906Medicaid