Provider Demographics
NPI:1508175464
Name:SADDLEBACK DIALYSIS LLC
Entity Type:Organization
Organization Name:SADDLEBACK DIALYSIS LLC
Other - Org Name:MAGNOLIA OAKS DIALYSIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR DIRECTOR LICENSURE&CERTIFICATION
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
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 DEPT.
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-7569
Mailing Address - Country:US
Mailing Address - Phone:615-320-4268
Mailing Address - Fax:877-238-0567
Practice Address - Street 1:2377 HWY 196 W
Practice Address - Street 2:
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313-8036
Practice Address - Country:US
Practice Address - Phone:912-368-2710
Practice Address - Fax:912-368-2714
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-27
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAESRD000739261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA11D2003617OtherCLIA
GA003101245AMedicaid
GA112831Medicare Oscar/Certification
GA11D2003617OtherCLIA