MEDICARE: HAVERHILLS 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

General Provider Information

NPI Number	:	1497345763
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HAVERHILLS DIALYSIS, LLC

Provider Business Mailing Address
First Line	:	5200 VIRGINIA WAY
Second Line	:
City	:	BRENTWOOD
State	:	TN
Zip	:	37027-7569
Country	:	US
Telephone Number	:	615-320-4283
Fax Number	:	800-320-3933

Provider Business Practice Location Address
First Line	:	2300 STATE ROAD 524 STE 106
Second Line	:
City	:	COCOA
State	:	FL
Zip	:	32926-5894
Country	:	US
Telephone Number	:	321-482-5609
Fax Number	:	321-482-5868

Authorized Official
Title or Position	:	CHIEF ACCOUNTING OFFICER
Name	:	JOHN WINSTEL
Credential	:
Telephone Number	:	303-405-5117

Provider Enumeration Date	:	01/21/2021
Last Update Date	:	01/21/2021

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