Provider Demographics
NPI:1962685636
Name:SOUTHWEST KIDNEY DAVITA DIALYSIS PARTNERS LLC
Entity Type:Organization
Organization Name:SOUTHWEST KIDNEY DAVITA DIALYSIS PARTNERS LLC
Other - Org Name:ARROWHEAD LAKES DIALYSIS CENTER
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:615-341-6814
Mailing Address - Fax:800-293-8405
Practice Address - Street 1:20325 N 51ST AVE
Practice Address - Street 2:BLDG 11 STE 184 & 186
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-4625
Practice Address - Country:US
Practice Address - Phone:623-533-6521
Practice Address - Fax:623-533-6579
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-17
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTC4389261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ345499Medicaid
AZ032604Medicare Oscar/Certification