Provider Demographics
NPI:1720759814
Name:LEGACY DIALYSIS OF RESTON LLC
Entity Type:Organization
Organization Name:LEGACY DIALYSIS OF RESTON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOYNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-729-5434
Mailing Address - Street 1:100 E SAMPLE RD STE 220
Mailing Address - Street 2:
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33064-3554
Mailing Address - Country:US
Mailing Address - Phone:954-781-7741
Mailing Address - Fax:888-349-8679
Practice Address - Street 1:1897 PRESTON WHITE DR STE 105
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20191-5475
Practice Address - Country:US
Practice Address - Phone:954-781-7741
Practice Address - Fax:888-349-8679
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-28
Last Update Date:2023-05-26
Deactivation Date:2023-03-04
Deactivation Code:
Reactivation Date:2023-05-26
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment