MEDICARE: UBONSIE 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	:	1740886274
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UBONSIE 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	:	615-238-3085
Fax Number	:	800-268-9682

Provider Business Practice Location Address
First Line	:	785 ORANGE DR
Second Line	:
City	:	VACAVILLE
State	:	CA
Zip	:	95687-3133
Country	:	US
Telephone Number	:	707-359-1960
Fax Number	:	707-359-1986

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

Provider Enumeration Date	:	12/09/2020
Last Update Date	:	07/14/2022

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