MEDICARE: EDISTO 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	550002921	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	:	1619397700
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EDISTO 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	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	13054 N HARBOR BLVD
Second Line	:
City	:	GARDEN GROVE
State	:	CA
Zip	:	92843-1744
Country	:	US
Telephone Number	:	714-539-3395
Fax Number	:	714-539-3467

Authorized Official
Title or Position	:	VP, LICENSURE & CERTIFICATION
Name	:	SAMUEL T. WEY
Credential	:
Telephone Number	:	615-341-6641

Provider Enumeration Date	:	04/16/2014
Last Update Date	:	06/07/2024

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Directions to “EDISTO DIALYSIS LLC ” Practice Location

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