Provider Demographics
NPI:1578649109
Name:PURITY DIALYSIS CENTERS, INC
Entity Type:Organization
Organization Name:PURITY DIALYSIS CENTERS, INC
Other - Org Name:MUKWONAGO DIALYSIS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING SUPERVISOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TINA
Authorized Official - Middle Name:M
Authorized Official - Last Name:WALDRON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-646-6426
Mailing Address - Street 1:2301 SUN VALLEY DR STE 200
Mailing Address - Street 2:
Mailing Address - City:DELAFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53018-2318
Mailing Address - Country:US
Mailing Address - Phone:262-646-4162
Mailing Address - Fax:262-646-2498
Practice Address - Street 1:400 BAY VIEW RD STE F
Practice Address - Street 2:
Practice Address - City:MUKWONAGO
Practice Address - State:WI
Practice Address - Zip Code:53149-1745
Practice Address - Country:US
Practice Address - Phone:262-363-1925
Practice Address - Fax:262-363-1928
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2010-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42053800Medicaid
WI52D0988765OtherMDC CLIA #
WI522521Medicare PIN