Provider Demographics
NPI:1710079876
Name:LA GRANGE DIALYSIS LLC
Entity Type:Organization
Organization Name:LA GRANGE DIALYSIS LLC
Other - Org Name:WEST BROADWAY DIALYSIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:O
Authorized Official - Last Name:USILTON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:770-541-7922
Mailing Address - Street 1:5200 VIRGINIA WAY
Mailing Address - Street 2:STE 400 L&C
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-7569
Mailing Address - Country:US
Mailing Address - Phone:615-320-4218
Mailing Address - Fax:303-209-7825
Practice Address - Street 1:720 W BROADWAY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-2216
Practice Address - Country:US
Practice Address - Phone:502-584-2059
Practice Address - Fax:502-584-2835
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2007-08-01
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
182581Medicare Oscar/Certification