MEDICARE: RANDOLPH 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

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	:	1659796233
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RANDOLPH 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	:	615-320-4514
Fax Number	:	866-594-9961

Provider Business Practice Location Address
First Line	:	6721 OLD TRAIL RD
Second Line	:	STE 100
City	:	FORT WAYNE
State	:	IN
Zip	:	46809-2655
Country	:	US
Telephone Number	:	260-478-8582
Fax Number	:	260-478-8566

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

Provider Enumeration Date	:	02/19/2014
Last Update Date	:	12/15/2022

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Directions to “RANDOLPH DIALYSIS LLC ” Practice Location

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