Provider Demographics
NPI:1376100818
Name:NICONA DIALYSIS LLC
Entity Type:Organization
Organization Name:NICONA DIALYSIS LLC
Other - Org Name:BRODIE LANE 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 DEPARTMENT
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-7569
Mailing Address - Country:US
Mailing Address - Phone:615-320-4224
Mailing Address - Fax:800-293-4707
Practice Address - Street 1:9010 BRODIE LANE
Practice Address - Street 2:BLDG A
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78748-5184
Practice Address - Country:US
Practice Address - Phone:512-280-6505
Practice Address - Fax:512-280-6866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-21
Last Update Date:2024-01-26
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
TX4087009-01Medicaid