Provider Demographics
NPI: | 1457853459 |
---|---|
Name: | ETTLETON DIALYSIS LLC |
Entity Type: | Organization |
Organization Name: | ETTLETON DIALYSIS LLC |
Other - Org Name: | MILPITAS 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: | 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: | 800-268-9682 |
Practice Address - Street 1: | 660 E CALAVERAS BLVD |
Practice Address - Street 2: | |
Practice Address - City: | MILPITAS |
Practice Address - State: | CA |
Practice Address - Zip Code: | 95035-5442 |
Practice Address - Country: | US |
Practice Address - Phone: | 408-945-6536 |
Practice Address - Fax: | 408-945-6549 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2018-03-06 |
Last Update Date: | 2022-07-21 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 261QE0700X | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |