MEDICARE: FLAGLER DIALYSIS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QE0700X	End-Stage Renal Disease (ESRD) Treatment Clinic/Center	240000808	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1346590106
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FLAGLER DIALYSIS LLC

Provider Business Mailing Address
First Line	:	5200 VIRGINIA WAY
Second Line	:	L&C DEPT.
City	:	BRENTWOOD
State	:	TN
Zip	:	37027-7569
Country	:	US
Telephone Number	:	615-341-6793
Fax Number	:	877-790-2174

Provider Business Practice Location Address
First Line	:	22620 GOLDENCREST DR
Second Line	:	STE 101
City	:	MORENO VALLEY
State	:	CA
Zip	:	92553-9032
Country	:	US
Telephone Number	:	951-656-3804
Fax Number	:	951-656-7508

Authorized Official
Title or Position	:	CHEIF ACCOUNTING OFFICER
Name	:	JOHN D. WINSTEL
Credential	:
Telephone Number	:	253-733-4501

Provider Enumeration Date	:	09/19/2012
Last Update Date	:	02/17/2021

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Directions to “FLAGLER DIALYSIS LLC ” Practice Location

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