Provider Demographics
NPI: | 1679817258 |
---|---|
Name: | JOSHUA DIALYSIS LLC |
Entity Type: | Organization |
Organization Name: | JOSHUA DIALYSIS LLC |
Other - Org Name: | ANDOVER 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 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: | 626 S ANDOVER RD STE 900 |
Practice Address - Street 2: | |
Practice Address - City: | ANDOVER |
Practice Address - State: | KS |
Practice Address - Zip Code: | 67002-8910 |
Practice Address - Country: | US |
Practice Address - Phone: | 316-733-2984 |
Practice Address - Fax: | 316-733-4138 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2012-11-20 |
Last Update Date: | 2023-12-21 |
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 |