Provider Demographics
NPI:1679829493
Name:PRINEVILLE DIALYSIS LLC
Entity Type:Organization
Organization Name:PRINEVILLE DIALYSIS LLC
Other - Org Name:POCONO HOME CENTER
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:615-341-6410
Mailing Address - Fax:888-662-8259
Practice Address - Street 1:3361 ROUTE 611
Practice Address - Street 2:STE 1
Practice Address - City:BARTONSVILLE
Practice Address - State:PA
Practice Address - Zip Code:18321-7821
Practice Address - Country:US
Practice Address - Phone:570-629-1292
Practice Address - Fax:570-629-2482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-30
Last Update Date:2020-04-06
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
PA1028331050001Medicaid
PA392804Medicare Oscar/Certification