Provider Demographics
NPI:1700832318
Name:ISD RENAL INC
Entity Type:Organization
Organization Name:ISD RENAL INC
Other - Org Name:LAKE ROAD DIALYSIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF ACCOUNTING OFFICER
Authorized Official - Prefix:MR
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:ATT: LICENSURE & CERTIFICATION
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-7569
Mailing Address - Country:US
Mailing Address - Phone:615-341-6814
Mailing Address - Fax:800-293-8405
Practice Address - Street 1:6902 SE LAKE RD
Practice Address - Street 2:STE 100
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97267-2148
Practice Address - Country:US
Practice Address - Phone:503-794-1288
Practice Address - Fax:503-794-5916
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2023-01-23
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
OR170060OtherSTATE
382534Medicare Oscar/Certification