Provider Demographics
NPI:1972764744
Name:LA GRANGE DIALYSIS LLC
Entity type:Organization
Organization Name:LA GRANGE DIALYSIS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:HILGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-382-1919
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:615-320-4521
Mailing Address - Fax:866-594-2894
Practice Address - Street 1:1937 OLD HIGHWAY 135 NW
Practice Address - Street 2:
Practice Address - City:CORYDON
Practice Address - State:IN
Practice Address - Zip Code:47112-2013
Practice Address - Country:US
Practice Address - Phone:812-738-5200
Practice Address - Fax:812-738-4935
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-24
Last Update Date:2008-09-25
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
KY7100049230Medicaid
IN200889000AMedicaid
KY7100049230Medicaid