Provider Demographics
NPI:1770686255
Name:NORTHERN SIERRA DIALYSIS CENTER, LLC.
Entity Type:Organization
Organization Name:NORTHERN SIERRA DIALYSIS CENTER, LLC.
Other - Org Name:NORTHERN SIERRA DIALYSIS CENTER AT SOUTH MEADOWS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:VAN WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:775-982-4027
Mailing Address - Street 1:1500 E 2ND ST STE 101
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-1189
Mailing Address - Country:US
Mailing Address - Phone:775-982-4027
Mailing Address - Fax:775-982-8104
Practice Address - Street 1:10085 DOUBLE R BLVD
Practice Address - Street 2:STE 160
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89511
Practice Address - Country:US
Practice Address - Phone:775-982-4027
Practice Address - Fax:775-982-8104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV3410ESR-4261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment