Provider Demographics
NPI:1407143712
Name:BLANCO DIALYSIS LLC
Entity Type:Organization
Organization Name:BLANCO DIALYSIS LLC
Other - Org Name:APPLE AVENUE 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:ATT: L&C DEPT
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-7569
Mailing Address - Country:US
Mailing Address - Phone:615-320-4514
Mailing Address - Fax:866-594-9961
Practice Address - Street 1:2480 E APPLE AVE
Practice Address - Street 2:UNIT E
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49442-4471
Practice Address - Country:US
Practice Address - Phone:231-773-0597
Practice Address - Fax:231-777-7050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-07
Last Update Date:2023-04-27
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
MI1407143712Medicaid